Asepsis and Infection Control PDF

CHAPTER 4 Asepsis and Infection Control FOCUSING ON PATIENT CARE This chapter will help you develop some of the skills related to asepsis and infection control necessary to care for the following patients: Joe Wilson, is scheduled to undergo a cardiac catheterization later this morning. Sheri Lawren...

CHAPTER 4 Asepsis and Infection Control FOCUSING ON PATIENT CARE This chapter will help you develop some of the skills related to asepsis and infection control necessary to care for the following patients: Joe Wilson, is scheduled to undergo a cardiac catheterization later this morning. Sheri Lawrence, has been ordered to have an indwelling urinary catheter inserted. Edgar Barowski, is suspected of having tuberculosis and requires infection-control precautions. LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Perform hand hygiene using soap and water (handwashing). 2. Perform hand hygiene using an alcohol-based hand rub. 3. Prepare a sterile field. 4. Add sterile items to a sterile field. 5. Put on and remove sterile gloves. 6. Put on and remove personal protective equipment safely. KEY TERMS healthcare-associated infection: infection not present on admission to healthcare agency; acquired during the course of treatment for other conditions medical asepsis: clean technique; involves procedures and practices that reduce the number and transfer of pathogens personal protective equipment (PPE): equipment and supplies necessary to minimize or prevent exposure to infectious material, including gloves, gowns, masks, and protective eye gear standard precautions: precautions used in the care of all hospitalized individuals regardless of their diagnosis or possible infection status; these precautions apply to blood, all body fluids, secretions and excretions (except sweat), nonintact skin, and mucous membranes surgical asepsis: sterile technique; involves practices used to render and keep objects and areas free from microorganisms transmission-based precautions: precautions used in addition to Standard Precautions for patients in hospitals who are suspected of being infected with pathogens that can be transmitted by airborne, droplet, or contact routes; these precautions encompass all the diseases or conditions previously listed in the diseasespecific or category-specific classifications 123 LWBK545_C04_p123-150.qxd 8/5/10 3:39 PM Page 124 Aptara Inc 124 UNIT I Actions Basic to Nursing Care Nurses and other healthcare workers play a key role in reducing the spread of disease, minimizing complications, and reducing adverse outcomes for their patients. Limiting the spread of microorganisms is accomplished by breaking the chain of infection. The practice of asepsis includes all activities to prevent infection or break the chain of infection. Medical asepsis, or clean technique, involves procedures and practices that reduce the number and transfer of pathogens. (Refer to Fundamentals Review 4-1.) Surgical asepsis, or sterile technique, includes practices used to render and keep objects and areas free from microorganisms. (Refer to Fundamentals Review 4-2.) This chapter reviews procedures to assist nurses in preventing the spread of infection, including the use of PPE, hand hygiene, and sterile technique. Hand hygiene is the most effective way to help prevent the spread of organisms. Refer to Fundamentals Review 4-3 for general guidelines regarding hand hygiene for healthcare workers. The CDC has reinforced previous guidelines that handwashing is the most effective way to help prevent disease transmission. However, it has looked at the use of other agents, and the guidelines include the routine use of alcohol-based hand rubs. Improved compliance with hand hygiene has been shown to reduce overall infection rates in healthcare facilities (CDC, 2002b). The Joint Commission (TJC) has included a recommendation to use hand hygiene as part of the 2009 Patient Safety Goal to “prevent infection” (TJC, 2008). In addition, as part of their “Speak Up” program, the Joint Commission encourages consumers to insist on hand hygiene measures from all healthcare staff involved in their care (TJC, 2007). The use of Standard and Transmission-Based Precautions is another important part of protecting patients and healthcare providers and preventing the spread of infection. Fundamentals Review 4-4 and Fundamentals Review 4-5 outline a summary of CDC recommended practices for Standard and Transmission-Based Precautions. Fundamentals Review 4-1 BASIC PRINCIPLES OF MEDICAL ASEPSIS IN PATIENT CARE Practice good hand hygiene techniques. Carry soiled items, including linens, equipment, and other used articles, away from the body to prevent them from touching the clothing. Do not place soiled bed linen or any other items on the floor, which is grossly contaminated. It increases contamination of both surfaces. Avoid having patients cough, sneeze, or breathe directly on others. Provide patients with disposable tissues, and instruct them, as indicated, to cover their mouth and nose to prevent spread by airborne droplets. Move equipment away from you when brushing, dusting, or scrubbing articles. This helps prevent contaminated particles from settling on your hair, face, and uniform. Avoid raising dust. Use a specially treated or a dampened cloth. Do not shake linens. Dust and lint particles constitute a vehicle by which organisms can be transported from one area to another. Clean the least soiled areas first and then move to the more soiled ones. This helps prevent having the cleaner areas soiled by the dirtier areas. Dispose of soiled or used items directly into appropriate containers. Wrap items that are moist from body discharge or drainage in waterproof containers, such as plastic bags, before discarding into the refuse holder so that handlers will not come in contact with them. Pour liquids that are to be discarded, such as bath water, mouth rinse, and the like, directly into the drain to avoid splattering in the sink and onto you. Sterilize items that are suspected of containing pathogens. After sterilization, they can be managed as clean items if appropriate. Use personal grooming habits that help prevent spreading microorganisms. Shampoo your hair regularly; keep your fingernails short and free of broken cuticles and ragged edges; do not wear false nails; and do not wear rings with grooves and stones that might harbor microorganisms. Follow guidelines conscientiously for infectioncontrol or barrier techniques as prescribed by the agency. LWBK545_C04_p123-150.qxd 8/5/10 3:39 PM Page 125 Aptara Inc CHAPTER 4 Asepsis and Infection Control 125 Fundamentals Review 4-2 BASIC PRINCIPLES OF SURGICAL ASEPSIS Only a sterile object can touch another sterile object. Unsterile touching sterile means contamination has occurred. Open sterile packages so that the first edge of the wrapper is directed away from the worker to avoid the possibility of a sterile surface touching unsterile clothing. The outside of the sterile package is considered contaminated. Avoid spilling any solution on a cloth or paper used as a field for a sterile setup. The moisture penetrates the sterile cloth or paper and carries organisms by capillary action to contaminate the field. A wet field is considered contaminated if the surface immediately below it is not sterile. Hold sterile objects above waist level. This will ensure keeping the object within sight and preventing accidental contamination. Avoid talking, coughing, sneezing, or reaching over a sterile field or object. This helps to prevent contami- nation by droplets from the nose and the mouth or by particles dropping from the worker’s arm. Never walk away from or turn your back on a sterile field. This prevents possible contamination while the field is out of the worker’s view. All items brought into contact with broken skin, used to penetrate the skin to inject substances into the body, or used to enter normally sterile body cavities should be sterile. These items include dressings used to cover wounds and incisions, needles for injection, and tubes (catheters) used to drain urine from the bladder. Use dry, sterile forceps when necessary. Forceps soaked in disinfectant are not considered sterile. Consider the outer 1-inch edge of a sterile field to be contaminated. Consider an object contaminated if you have any doubt about its sterility. Fundamentals Review 4-3 HAND HYGIENE FOR HEALTHCARE WORKERS HAND HYGIENE IS REQUIRED Before and after contact with each patient Before putting on sterile gloves Before performing any invasive procedure, such as placement of a peripheral vascular catheter After accidental contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings, even if hands are not visibly soiled When moving from a contaminated body site to a clean body site during patient care After contact with inanimate objects near the patient After removal of gloves ADDITIONAL GUIDELINES The use of gloves does not eliminate the need for hand hygiene. The use of hand hygiene does not eliminate the need for gloves. Natural fingernails should be kept less than 1/4 inch long. Artificial fingernails or extenders should not be worn when having direct contact with patients at high risk. Gloves should be worn when contact with blood, infectious material, mucous membranes, and nonintact skin could occur. Hand lotions or creams are recommended to moisturize and protect skin related to the occurrence of irritant dermatitis associated with hand hygiene. (Modified with permission from Centers for Disease Control and Prevention. Guidelines for hand hygiene in healthcare settings. Morbidity and Mortality Weekly Report, 51(RR16), 1–45.) LWBK545_C04_p123-150.qxd 8/5/10 3:39 PM Page 126 Aptara Inc 126 UNIT I Actions Basic to Nursing Care Fundamentals Review 4-4 STANDARD PRECAUTIONS Standard Precautions are to be used for all patients receiving care in hospitals without regard to their diagnosis or presumed infection status. Standard Precautions apply to blood; all body fluids, secretions, and excretions except sweat, regardless of the presence of visible blood; nonintact skin; and mucous membranes. Standard Precautions reduce the risk of transmission of microorganisms that cause infections in hospitals. STANDARD PRECAUTIONS (TIER 1) Follow hand hygiene techniques. Wear clean, nonsterile gloves when touching blood, body fluids, excretions, secretions, contaminated items, mucous membranes, and nonintact skin. Change gloves between tasks on the same patient, as necessary, and remove gloves promptly after use. Wear personal protective equipment, such as mask, eye protection, face shield, or fluid-repellent gown during procedures and care activities that are likely to generate splashes or sprays of blood or body fluids. Use gown to protect skin and prevent soiling of clothing. Avoid recapping used needles. If you must recap, never use two hands. Use a needle-recapping device or the one-handed scoop technique. Place needles, sharps, and scalpels in appropriate puncture-resistant containers after use. Carefully handle used patient-care equipment that is soiled with blood or identified body fluids, secretions, and excretions to prevent transfer of microorganisms. Clean and reprocess items appropriately if used for another patient. Fundamentals Review 4-5 TRANSMISSION-BASED PRECAUTIONS Transmission-Based Precautions are used in addition to Standard Precautions for patients in hospitals with suspected infection with pathogens that can be transmitted by airborne, droplet, or contact routes. Any of the three types can be used in combination with the others. Equipment required for patient care, such as a thermometer, sphygmomanometer, and stethoscope, should be disposable, kept in the patient’s room, and not used for other patients. AIRBORNE PRECAUTIONS (TIER 2) Use Airborne Precautions for patients who have infections that spread through the air, such as tuberculosis, varicella (chicken pox), rubeola (measles), and possibly severe acute respiratory syndrome (SARS). Place patient in private room that has monitored negative air pressure in relation to surrounding areas, 6 to 12 air changes per hour, and appropriate discharge of air outside or monitored filtration if air is recirculated. Keep door closed and patient in room. Use respiratory protection when entering room of patient with known or suspected tuberculosis. If patient has known or suspected rubeola or varicella, respiratory protection should be worn unless the person entering the room is immune to these diseases. Transport patient out of room only when necessary and place a surgical mask on the patient if possible. Consult CDC Guidelines for additional prevention strategies for tuberculosis. DROPLET PRECAUTIONS Use Droplet Precautions for patients with an infection that is spread by large-particle droplets, such as rubella, mumps, diphtheria, and the adenovirus infection in infants and young children. Use a private room, if available. Door may remain open. Wear PPE upon entry into the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patient’s environment. Transport patient out of the room only when necessary and place a surgical mask on the patient if possible. Keep visitors 3 feet from the infected person. CONTACT PRECAUTIONS Use Contact Precautions for patients who are infected or colonized by a multidrug-resistant organism (MDRO). Place patient in a private room if available. 127 CHAPTER 4 Asepsis and Infection Control Fundamentals Review 4-5 continued TRANSMISSION-BASED PRECAUTIONS Wear PPE whenever you enter the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patient’s environment. Change gloves after having contact with infective material. Remove PPE before leaving the patient environment, and wash hands with an antimicrobial or waterless antiseptic agent. Wear a gown if contact with an infectious agent is likely or patient has diarrhea, an ileostomy, 4-1 colostomy, or wound drainage not contained by a dressing. Limit movement of the patient out of the room. Avoid sharing patient-care equipment. (Adapted from Centers for Disease Control and Prevention (CDC). (2007d). Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Available at www.cdec.gov/mcidod/dhqp/pdf/guidelines/ Isolation2007.pdf. Accessed June 12, 2009.) Performing Hand Hygiene Using Soap and Water (Handwashing) Handwashing remains the best method to decontaminate hands. Handwashing, as opposed to hand hygiene with an alcohol-based rub, is required (CDC, 2002a): When hands are visibly dirty When hands are visibly soiled with or in contact with blood or other body fluids Before eating and after using the restroom If exposure to certain organisms, such as those causing anthrax or Clostridium difficile, is known or suspected. (Other agents have poor activity against these organisms.) EQUIPMENT Antimicrobial or non-antimicrobial soap (if in bar form, soap must be placed on a soap rack) Paper towels Oil-free lotion (optional) ASSESSMENT Assess for any of the above requirements for handwashing. If no requirements are fulfilled, the caregiver has the option of decontaminating hands with soap and water or using an alcohol-based hand rub. NURSING DIAGNOSIS Determine the related factors for the nursing diagnoses based on the patient’s current status. An appropriate nursing diagnosis is Risk for Infection. Many other nursing diagnoses also may require the use of this skill. OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when performing handwashing is that the hands will be free of visible soiling and transient microorganisms will be eliminated. Other outcomes may be appropriate depending on the specific nursing diagnosis identified for the patient. IMPLEMENTATION ACTION R AT I O N A L E 1. Gather the necessary supplies. Stand in front of the sink. Do not allow your clothing to touch the sink during the washing procedure (Figure 1). The sink is considered contaminated. Clothing may carry organisms from place to place. 2. Remove jewelry, if possible, and secure in a safe place. A plain wedding band may remain in place. Removal of jewelry facilitates proper cleansing. Microorganisms may accumulate in settings of jewelry. If jewelry was worn during care, it should be left on during handwashing. 3. Turn on water and adjust force (Figure 2). Regulate the temperature until the water is warm. Water splashed from the contaminated sink will contaminate clothing. Warm water is more comfortable and is less likely to open pores and remove oils from the skin. Organisms can lodge in roughened and broken areas of chapped skin. (continued) LWBK545_C04_p123-150.qxd 8/5/10 3:40 PM Page 128 Aptara Inc 128 UNIT I 4-1 Actions Basic to Nursing Care Performing Hand Hygiene Using Soap and Water (Handwashing) continued ACTION FIGURE 1. Standing in front of sink. R AT I O N A L E FIGURE 2. Turning on the water at the sink. 4. Wet the hands and wrist area. Keep hands lower than elbows to allow water to flow toward fingertips (Figure 3). Water should flow from the cleaner area toward the more contaminated area. Hands are more contaminated than forearms. 5. Use about 1 teaspoon liquid soap from dispenser or rinse bar of soap and lather thoroughly (Figure 4). Cover all areas of hands with the soap product. Rinse soap bar again and return to soap rack. Rinsing the soap before and after use removes the lather, which may contain microorganisms. FIGURE 3. Wetting hands to the wrist. FIGURE 4. Lathering hands with soap and rubbing with firm circular motion. 6. With firm rubbing and circular motions, wash the palms and backs of the hands, each finger, the areas between the fingers (Figure 5), and the knuckles, wrists, and forearms. Wash at least 1 inch above area of contamination. If hands are not visibly soiled, wash to 1 inch above the wrists (Figure 6). Friction caused by firm rubbing and circular motions helps to loosen dirt and organisms that can lodge between the fingers, in skin crevices of knuckles, on the palms and backs of the hands, and on the wrists and forearms. Cleaning less contaminated areas (forearms and wrists) after hands are clean prevents spreading microorganisms from the hands to the forearms and wrists. 7. Continue this friction motion for at least 15 seconds. Length of handwashing is determined by degree of contamination. 8. Use fingernails of the opposite hand or a clean orangewood stick to clean under fingernails (Figure 7). Area under nails has a high microorganism count, and organisms may remain under the nails, where they can grow and be spread to other persons. 9. Rinse thoroughly with water flowing toward fingertips (Figure 8). Running water rinses microorganisms and dirt into the sink. LWBK545_C04_p123-150.qxd 08/05/2010 7:29 PM Page 129 Aptara 129 CHAPTER 4 Asepsis and Infection Control ACTION R AT I O N A L E FIGURE 5. Washing areas between fingers. FIGURE 6. Washing to 1 inch above the wrist. FIGURE 7. Using fingernails to clean under nails of opposite FIGURE 8. Rinsing hands under running water with water hand. flowing toward fingertips. 10. Pat hands dry with a paper towel, beginning with the fingers and moving upward toward forearms, and discard it immediately. Use another clean towel to turn off the faucet. Discard towel immediately without touching other clean hand. Patting the skin dry prevents chapping. Dry hands first because they are considered the cleanest and least contaminated area. Turning the faucet off with a clean paper towel protects the clean hands from contact with a soiled surface. 11. Use oil-free lotion on hands if desired. Oil-free lotion helps to keep the skin soft and prevents chapping. It is best applied after patient care is complete and from small, personal containers. Oil-based lotions should be avoided because they can cause deterioration of gloves. EVALUATION The expected outcome is met when the hands are free of visible soiling and transient microorganisms are eliminated. DOCUMENTATION The performance of handwashing is not generally documented. SPECIAL CONSIDERATIONS General Considerations An antimicrobial soap product is recommended for use with handwashing before participating in an invasive procedure and after exposure to blood or body fluids. The length of the scrub will vary based on need. Liquid or bar soap, granules, or leaflets are all acceptable forms of non-antimicrobial soap. (continued) 130 UNIT I Actions Basic to Nursing Care 4-1 Performing Hand Hygiene Using Soap and Water (Handwashing) continued Home Care Considerations Home care providers should consider bringing their own liquid soap and disposable paper towels into the home for washing and drying their hands instead of using potentially contaminated bar soap and towels in the patient’s home (Grossman & DeBartolomeo, 2008). Proper hand hygiene before leaving a home and immediately upon entering another home is imperative (McGoldrick & Rhinehart, 2007). EVIDENCE FOR PRACTICE Prevention of healthcare-associated infections is a major challenge for healthcare providers. Hand hygiene is regarded as an effective preventive measure. This procedure is still not performed consistently in healthcare settings, however (Institute for Healthcare Improvement, 2006a). Related Research Gould, D., Chudleigh, J., Moralejo, D., et al. (2009). Interventions to improve hand hygiene compliance in patient care. The Cochrane Database of Systematic Reviews, Vol. 2. Available at www.cochrane.org/reviews/ en/ab005186.html. Accessed June 16, 2009. The objective of this literature review was to assess the short- and longer-term success of strategies to improve hand hygiene compliance and to determine whether sustained increase in hand hygiene compliance can reduce rates of healthcare-associated infection. Two studies met the criteria for review. Statistically significant postintervention increase in handwashing was reported in one study up to 4 months after the intervention. In the other, there was no postintervention increase in hand hygiene compliance. The authors concluded there is little robust evidence to influence the choice of interventions to improve hand hygiene. They identified a need to undertake methodologically robust research to explore the effectiveness of soundly designed interventions to increase hand hygiene compliance. Relevance for Nursing Practice Effective hand hygiene is a mandatory part of nursing care. Nurses should consider undertaking studies related to improving hand hygiene compliance to ensure safe patient care. Such studies would also add to the body of knowledge to support evidence-based nursing practice. EVIDENCE FOR PRACTICE Prevention of healthcare-associated infections is a major challenge for healthcare providers. Hand hygiene is regarded as an effective preventive measure. The World Health Organization has prepared guidelines for hand hygiene and is studying the acceptability of these guidelines in different healthcare settings worldwide. Related Research Allegranzi, B., Memish, Z., Donaldson, L., et al. (2009). World Health Organization Global Patient Safety Challenge Task Force on Religious and Cultural Aspects of Hand Hygiene. Religion and culture: Potential undercurrents influencing hand hygiene promotion in health care. American Journal of Infection Control, 37(1), 28–34. The authors conducted a literature search and consulted experts and religious authorities to investigate religiocultural factors that may potentially influence hand hygiene promotion, offer possible solutions, and suggest areas for future research. Data were retrieved on specific indications for hand cleansing according to the seven main religions worldwide, interpretation of hand gestures, the concept of “visibly dirty” hands, and the use of alcohol-based hand rubs and prohibition of alcohol use by some religions. They concluded that religious faith and culture can strongly influence hand hygiene behavior in healthcare workers and potentially affect compliance with best practices. Relevance for Nursing Practice Nurses need to consider the impact of religious faith and cultural specificities when implementing patient care and teaching related to handwashing and hand hygiene. CHAPTER 4 Asepsis and Infection Control 4-2 131 Performing Hand Hygiene Using an Alcohol-Based Hand Rub Alcohol-based hand rubs can be used in the healthcare setting and take less time to use than traditional handwashing. When using these products, check the product labeling for correct amount of product needed. Alcohol-based hand rubs (CDC, 2002a; 2002b): May be used if hands are not visibly soiled, or have not come in contact with blood or body fluids Should be used before and after each patient contact, or contact with surfaces in the patient’s environment Significantly reduce the number of microorganisms on skin; they are fast acting, and cause less skin irritation. EQUIPMENT Alcohol-based hand rub Oil-free lotion (optional) ASSESSMENT Assess hands for any visible soiling or contact with blood or body fluids. Alcohol-based hand rubs can be used if hands are not visibly soiled, or have not come in contact with blood or body fluids. If food is to be eaten, or the nurse has used the restroom, hands must be washed with soap and water. If hands are visibly soiled, proceed with washing the hands with soap and water. If hands have been in contact with blood or body fluids, even if there is no visible soiling, proceed with washing the hands with soap and water. NURSING DIAGNOSIS Determine the related factors for the nursing diagnoses based on the patient’s current status. An appropriate nursing diagnosis is Risk for Infection. Many other nursing diagnoses also may require the use of this skill. OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when performing hand decontamination with alcohol-based rubs is that transient microorganisms will be eliminated from the hands. Other outcomes may be appropriate depending on the specific nursing diagnosis identified for the patient. IMPLEMENTATION ACTION R AT I O N A L E 1. Remove jewelry, if possible, and secure in a safe place. A plain wedding band may remain in place. Removal of jewelry facilitates proper cleansing. Microorganisms may accumulate in settings of jewelry. If jewelry was worn during care, it should be left on during handwashing. 2. Check the product labeling for correct amount of product needed (Figure 1). Amount of product required to be effective varies from manufacturer to manufacturer, but is usually 1 to 3 mL. FIGURE 1. Checking product label for correct amount of product needed. (continued) 132 UNIT I Actions Basic to Nursing Care 4-2 Performing Hand Hygiene Using an Alcohol-Based Hand Rub continued ACTION R AT I O N A L E 3. Apply the correct amount of product to the palm of one hand. Rub hands together, covering all surfaces of hands and fingers, and between fingers. Also clean the fingertips and the area beneath the fingernails. Adequate amount of product is required to thoroughly cover hand surfaces. All surfaces must be treated to prevent disease transmission. 4. Rub hands together until they are dry (at least 15 seconds). Drying ensures antiseptic effect. 5. Use oil-free lotion on hands if desired. Oil-free lotion helps to keep the skin soft and prevents chapping. It is best applied after patient care is complete and from small, personal containers. Oil-based lotions should be avoided because they can cause deterioration of gloves. EVALUATION The expected outcome is met when transient microorganisms are eliminated from the hands. DOCUMENTATION The performance of hand hygiene using an alcohol-based hand rub is not generally documented. SPECIAL CONSIDERATIONS Home Care Proper hand hygiene, including the use of alcohol-based hand rubs, is imperative before leaving a home and immediately upon entering another home (McGoldrick & Rhinehart, 2007). 4-3 Preparing a Sterile Field Using a Packaged Sterile Drape A sterile field is created to provide a surgically aseptic workspace. It should be considered a restricted area. A sterile drape may be used to establish a sterile field or to extend the sterile working area. The sterile drape should be waterproof on one side, with that side placed down on the work surface. After establishing the sterile field, other sterile items needed, including solutions, are added. Sterile items and sterile gloved hands are the only objects allowed in the sterile field. Refer to Fundamentals Review 4-2 to review basic principles of surgical asepsis. EQUIPMENT Sterile wrapped drape Additional sterile supplies, such as dressings, containers, or solution, as needed PPE, as indicated ASSESSMENT Assess the situation to determine the necessity for creating a sterile field. Assess the area in which the sterile field is to be prepared. Move any unnecessary equipment out of the immediate vicinity. NURSING DIAGNOSIS Determine the related factors for the nursing diagnoses based on the patient’s current status. Appropriate nursing diagnoses may include: Risk for Infection Ineffective Protection OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when preparing a sterile field is that the sterile field is created without contamination and the patient remains free of exposure to potential infection-causing microorganisms. LWBK545_C04_p123-150.qxd 8/5/10 3:40 PM Page 133 Aptara Inc 133 CHAPTER 4 Asepsis and Infection Control IMPLEMENTATION ACTION R AT I O N A L E 1. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 2. Identify the patient. Explain the procedure to the patient. Patient identification validates the correct patient and correct procedure. Discussion and explanation help allay anxiety and prepare the patient for what to expect. 3. Check that packaged sterile drape is dry and unopened. Also note expiration date, making sure that the date is still valid. Moisture contaminates a sterile package. Expiration date indicates period that package remains sterile. 4. Select a work area that is waist level or higher. Work area is within sight. Bacteria tend to settle, so there is less contamination above the waist. 5. Open the outer covering of the drape. Remove sterile drape, lifting it carefully by its corners. Hold away from body and above the waist and work surface. Outer 1 inch (2.5 cm) of drape is considered contaminated. Any item touching this area is also considered contaminated. 6. Continue to hold only by the corners. Allow the drape to unfold, away from your body and any other surface (Figure 1). Touching the outer side of the wrapper maintains sterile field. Contact with any surface would contaminate the field. 7. Position the drape on the work surface with the moisture-proof side down (Figure 2). This would be the shiny or blue side. Avoid touching any other surface or object with the drape. If any portion of the drape hangs off the work surface, that part of the drape is considered contaminated. Moisture-proof side prevents contamination of the field if it becomes wet. The moisture penetrates the sterile cloth or paper and carries organisms by capillary action to contaminate the field. A wet field is considered contaminated if the surface immediately below it is not sterile. FIGURE 1. Holding drape by corners and allowing it to unfold FIGURE 2. Positioning drape on work surface with the moisture- away from body and surfaces. proof side down. 8. Place additional sterile items on field as needed. Refer to Skill 4-5. Continue with the procedure as indicated. Sterility of the field is maintained. 9. When procedure is completed, remove PPE, if used. Perform hand hygiene. Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. EVALUATION The expected outcome is met when the sterile field is prepared without contamination and the patient has remained free of exposure to potentially infectious microorganisms. DOCUMENTATION It is not usually necessary to document the preparation of a sterile field. However, document the use of sterile technique for any procedure performed using sterile technique. (continued) 134 UNIT I 4-3 Actions Basic to Nursing Care Preparing a Sterile Field Using a Packaged Sterile Drape UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS 4-4 continued A part of the sterile field becomes contaminated: When any portion of the sterile field becomes contaminated, discard all portions of the sterile field and start over. The nurse realizes a supply is missing after setting up the sterile field: Call for help. Do not leave the sterile field unattended. If the nurse is not able to visualize the sterile field at all times, it is considered contaminated. The patient touches the sterile field: If the patient touches the sterile field, discard the supplies and prepare a new sterile field. If the patient is confused, have someone assist by holding the patient’s hands and/or reinforcing what is happening. Preparing a Sterile Field Using a Commercially Prepared Sterile Kit or Tray A sterile field is created to provide a surgically aseptic workspace. It should be considered a restricted area. Commercially prepared sterile kits and trays are wrapped in a sterile wrapper that, once opened, becomes the sterile field. Sterile items and sterile gloved hands are the only objects allowed in the sterile field. If the area is breached, the entire sterile field is considered contaminated. Refer to Fundamentals Review 4-2 for guidelines related to working with a sterile field. EQUIPMENT Commercially prepared sterile package Additional sterile supplies, such as dressings, containers, or solution, as needed PPE, as indicated ASSESSMENT Assess the situation to determine the necessity for creating a sterile field. Assess the area in which the sterile field is to be prepared. Move any unnecessary equipment out of the immediate vicinity. NURSING DIAGNOSIS Determine the related factors for the nursing diagnoses based on the patient’s current status. Appropriate nursing diagnoses may include: Risk for Infection Ineffective Protection In addition, other nursing diagnoses also may require the use of this skill. OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when opening a commercially packaged sterile kit or tray is that a sterile field is created without contamination, the contents of the package remain sterile, and the patient remains free of exposure to potential infection-causing microorganisms. IMPLEMENTATION ACTION R AT I O N A L E 1. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 2. Identify the patient. Explain the procedure to the patient. Patient identification validates the correct patient and correct procedure. Discussion and explanation help allay anxiety and prepare the patient for what to expect. 3. Check that the packaged kit or tray is dry and unopened. Also note expiration date, making sure that the date is still valid. Moisture contaminates a sterile package. Expiration date indicates period that package remains sterile. 4. Select a work area that is waist level or higher. Work area is within sight. Bacteria tend to settle, so there is less contamination above the waist. LWBK545_C04_p123-150.qxd 8/5/10 3:40 PM Page 135 Aptara Inc 135 CHAPTER 4 Asepsis and Infection Control ACTION R AT I O N A L E 5. Open the outside cover of the package and remove the kit or tray (Figure 1). Place in the center of the work surface, with the topmost flap positioned on the far side of the package. This allows sufficient room for sterile field. 6. Reach around the package and grasp the outer surface of the end of the topmost flap, holding no more than 1 inch from the border of the flap. Pull open away from the body, keeping the arm outstretched and away from the inside of the wrapper (Figure 2). Allow the wrapper to lie flat on the work surface. This maintains sterility of inside of wrapper, which is to become the sterile field. Outer surface of the wrapper is considered unsterile. Outer 1-inch border of the wrapper is considered contaminated. FIGURE 1. Opening outside cover of package. FIGURE 2. Pulling top flap open, away from body. 7. Reach around the package and grasp the outer surface of the first side flap, holding no more than 1 inch from the border of the flap. Pull open to the side of the package, keeping the arm outstretched and away from the inside of the wrapper (Figure 3). Allow the wrapper to lie flat on the work surface. This maintains sterility of inside of wrapper, which is to become the sterile field. Outer surface of the wrapper is considered unsterile. Outer 1-inch border of the wrapper is considered contaminated. 8. Reach around the package and grasp the outer surface of the remaining side flap, holding no more than 1 inch from the border of the flap. Pull open to the side of the package, keeping the arm outstretched and away from the inside of the wrapper (Figure 4). Allow the wrapper to lie flat on the work surface. This maintains sterility of inside of wrapper, which is to become the sterile field. Outer surface of the wrapper is considered unsterile. Outer 1 inch of border of the wrapper is considered contaminated. FIGURE 3. Pulling open the first side flap. FIGURE 4. Pulling open the remaining side flap. (continued) LWBK545_C04_p123-150.qxd 8/5/10 3:40 PM Page 136 Aptara Inc 136 UNIT I 4-4 Actions Basic to Nursing Care Preparing a Sterile Field Using a Commercially Prepared Sterile Kit or Tray continued ACTION 9. Stand away from the package and work surface. Grasp the outer surface of the remaining flap closest to the body, holding not more than 1 inch from the border of the flap. Pull the flap back toward the body, keeping arm outstretched and away from the inside of the wrapper (Figure 5). Keep this hand in place. Use other hand to grasp the wrapper on the underside (the side that is down to the work surface). Position the wrapper so that when flat, edges are on the work surface, and do not hang down over sides of work surface (Figure 6). Allow the wrapper to lie flat on the work surface. R AT I O N A L E This maintains sterility of the inside of the wrapper, which is to become the sterile field. Outer surface of the wrapper is considered unsterile. Outer 1-inch border of the wrapper is considered contaminated. FIGURE 5. Pulling open flap closest to body. FIGURE 6. Positioning wrapper on work surface. 10. The outer wrapper of the package has become a sterile field with the packaged supplies in the center (Figure 7). Do not touch or reach over the sterile field. Place additional sterile items on field as needed. Refer to Skill 4-5. Continue with the procedure as indicated. Sterility of the field and contents are maintained. FIGURE 7. Outside wrapper of package is now sterile field. 11. When procedure is completed, remove PPE, if used. Perform hand hygiene. Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. 137 CHAPTER 4 Asepsis and Infection Control EVALUATION The expected outcome is met when the sterile field is prepared without contamination, the contents of the package remain sterile, and the patient remains free of exposure to potential infection-causing microorganisms. DOCUMENTATION It is not usually necessary to document the preparation of a sterile field. However, do document the use of sterile technique for any procedure performed using sterile technique. UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS A part of the sterile field becomes contaminated: When any portion of the sterile field becomes contaminated, discard all portions of the sterile field and start over. You realize a supply is missing after setting up the sterile field: Call for help. Do not leave the sterile field unattended. If you are unable to visualize the sterile field at all times, it is considered contaminated. The patient touches the sterile field: If the patient touches the sterile field, discard the supplies and prepare a new sterile field. If the patient is confused, have someone assist by holding the patient’s hands and/or reinforcing what is happening. 4-5 Adding Sterile Items to a Sterile Field A sterile field is created to provide a surgically aseptic workspace. It should be considered a restricted area. After establishing the sterile field, other sterile items needed, including solutions, are added. Items can be wrapped and sterilized within the agency or can be commercially prepared. Take care to ensure that nothing unsterile touches the field or other items in the field, including hands or clothes. Refer to Fundamentals Review 4-2 for guidelines related to working with a sterile field. EQUIPMENT Sterile field Sterile gauze, forceps, dressings, containers, solutions, or other sterile supplies as needed PPE, as indicated ASSESSMENT Assess the situation to determine the necessity for creating a sterile field. Assess the area in which the sterile field is to be prepared. Move any unnecessary equipment out of the immediate vicinity. Identify additional supplies needed for the procedure. NURSING DIAGNOSIS Determine the related factors for the nursing diagnoses based on the patient’s current status. Appropriate nursing diagnoses may include: Risk for Infection Ineffective Protection In addition, other nursing diagnoses also may require the use of this skill. OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when adding items to a sterile field is that the sterile field is created without contamination, the sterile supplies are not contaminated, and the patient remains free of exposure to potential infection-causing microorganisms. IMPLEMENTATION ACTION 1. Perform hand hygiene and put on PPE, if indicated. R AT I O N A L E Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. (continued) LWBK545_C04_p123-150.qxd 8/5/10 3:40 PM Page 138 Aptara Inc 138 UNIT I Actions Basic to Nursing Care 4-5 Adding Sterile Items to a Sterile Field ACTION 2. Identify the patient. Explain the procedure to the patient. continued R AT I O N A L E Patient identification validates the correct patient and correct procedure. Discussion and explanation help allay anxiety and prepare the patient for what to expect. 3. Check that the sterile, packaged drape and supplies are dry and unopened. Also note expiration date, making sure that the date is still valid. Moisture contaminates a sterile package. Expiration date indicates period that package remains sterile. 4. Select a work area that is waist level or higher. Work area is within sight. Bacteria tend to settle, so there is less contamination above the waist. 5. Prepare sterile field as described in Skill 4-3 or Skill 4-4. Proper technique maintains sterility. 6. Add sterile item: To Add an Agency-Wrapped and Sterilized Item a. Hold agency-wrapped item in the dominant hand, with top flap opening away from the body. With other hand, reach around the package and unfold top flap and both sides. Only sterile surface and item are exposed before dropping onto sterile field. b. Keep a secure hold on the item through the wrapper with the dominant hand. Grasp the remaining flap of the wrapper closest to the body, taking care not to touch the inner surface of the wrapper or the item. Pull the flap back toward the wrist, so the wrapper covers the hand and wrist. Only sterile surface and item are exposed before dropping onto sterile field. c. Grasp all the corners of the wrapper together with the nondominant hand and pull back toward wrist, covering hand and wrist. Hold in place. Only sterile surface and item are exposed before dropping onto sterile field. d. Hold the item 6 inches above the surface of the sterile field and drop onto the field. Be careful to avoid touching the surface or other items or dropping onto the 1-inch border. This prevents contamination of the field and inadvertent dropping of the sterile item too close to the edge or off the field. Any items landing on the 1-inch border are considered contaminated. To Add a Commercially Wrapped and Sterilized Item a. Hold package in one hand. Pull back top cover with other hand. Alternately, carefully peel the edges apart using both hands (Figure 1). Contents remain uncontaminated by hands. b. After top cover or edges are partially separated, hold the item 6 inches above the surface of the sterile field. Continue opening the package and drop the item onto the field (Figure 2). Be careful to avoid touching the surface or other items or dropping onto the 1-inch border. This prevents contamination of the field and inadvertent dropping of the sterile item too close to the edge or off the field. Any items landing on the 1-inch border are considered contaminated. c. Discard wrapper. A neat work area promotes proper technique and avoids inadvertent contamination of the field. FIGURE 1. Carefully peeling edges apart. FIGURE 2. Dropping sterile item onto sterile field. LWBK545_C04_p123-150.qxd 8/5/10 3:40 PM Page 139 Aptara Inc CHAPTER 4 Asepsis and Infection Control ACTION 139 R AT I O N A L E To Add a Sterile Solution a. Obtain appropriate solution and check expiration date. Once opened, a bottle should be labeled with date and time. Solution remains sterile for 24 hours once opened. b. Open solution container according to directions and place cap on table away from the field with edges up (Figure 3). Sterility of inside cap is maintained. c. Hold bottle outside the edge of the sterile field with the label side facing the palm of your hand and prepare to pour from a height of 4 to 6 inches (10 to 15 cm). The tip of the bottle should never touch a sterile container or field. Label remains dry, and solution may be poured without reaching across sterile field. Minimal splashing occurs from that height. Accidentally touching the tip of the bottle to a container or dressing contaminates them both. d. Pour required amount of solution steadily into sterile container previously added to the sterile field and positioned at side of sterile field or onto dressings (Figure 4). Avoid splashing any liquid. A steady stream minimizes the risk of splashing; moisture contaminates sterile field. e. Touch only the outside of the lid when recapping. Label solution with date and time of opening. Solution remains uncontaminated and available for future use. FIGURE 3. Opening bottle of sterile solution and placing cap on FIGURE 4. Pouring solution into sterile container. table with edges up. 7. Continue with procedure as indicated. 8. When procedure is completed, remove PPE, if used. Perform hand hygiene. Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. EVALUATION The expected outcome to achieve when adding items to a sterile field is that the sterile field is created without contamination, the sterile supplies are not contaminated, and the patient remains free of exposure to potential infection-causing microorganisms. DOCUMENTATION It is not usually necessary to document the addition of sterile items to a sterile field. However, document the use of sterile technique for any procedure performed using sterile technique. UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS The item being added falls close to or on the edge of the field: Consider the outer 1-inch edge of a sterile field to be contaminated. Any item within the outer 1 inch is considered contaminated. A part of the sterile field becomes contaminated: When any portion of the sterile field becomes contaminated, discard all portions of the sterile field and start over. You realize a supply is missing after setting up the sterile field: Call for help. Do not leave the sterile field unattended. If you are unable to visualize the sterile field at all times, it is considered contaminated. The patient touches the sterile field: If the patient touches the sterile field, discard the supplies and prepare a new sterile field. If the patient is confused, have someone assist by holding the patient’s hands and/or reinforcing what is happening. 140 UNIT I Actions Basic to Nursing Care 4-6 Putting on Sterile Gloves and Removing Soiled Gloves When applying and wearing sterile gloves, keep hands above waist level and away from nonsterile surfaces. Replace gloves if they develop an opening or tear, the integrity of the material becomes compromised, or the gloves come in contact with any unsterile surface or unsterile item. Refer to Fundamentals Review 4-2 for additional guidelines related to working with sterile gloves. It is a good idea to bring an extra pair of gloves with you when gathering supplies, according to facility policy. That way, if the first pair is contaminated in some way and needs to be replaced, you will not have to leave the procedure to get a new pair. EQUIPMENT Sterile gloves of the appropriate size PPE, as indicated ASSESSMENT Assess the situation to determine the necessity for sterile gloves. In addition, check the patient’s chart for information about a possible latex allergy. Also, question the patient about any history of allergy, including latex allergy or sensitivity and signs and symptoms that have occurred. If the patient has a latex allergy, anticipate the need for latex-free gloves. NURSING DIAGNOSIS Determine the related factors for the nursing diagnoses based on the patient’s current status. An appropriate nursing diagnosis is Risk for Infection. Other nursing diagnoses that may be appropriate include: Ineffective Protection Risk for Latex Allergy Response OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when putting on and removing sterile gloves is that the gloves are applied and removed without contamination. Other outcomes that may be appropriate include the following: the patient remains free of exposure to infectious microorganisms, and the patient does not exhibit signs and symptoms of a latex allergy response. IMPLEMENTATION ACTION R AT I O N A L E 1. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 2. Identify the patient. Explain the procedure to the patient. Patient identification validates the correct patient and correct procedure. Discussion and explanation help allay anxiety and prepare the patient for what to expect. 3. Check that the sterile glove package is dry and unopened. Also note expiration date, making sure that the date is still valid. Moisture contaminates a sterile package. Expiration date indicates the period that the package remains sterile. 4. Place sterile glove package on clean, dry surface at or above your waist. Moisture could contaminate the sterile gloves. Any sterile object held below the waist is considered contaminated. 5. Open the outside wrapper by carefully peeling the top layer back (Figure 1). Remove inner package, handling only the outside of it. This maintains sterility of gloves in inner packet. 6. Place the inner package on the work surface with the side labeled ‘cuff end’ closest to the body. Allows for ease of glove application. 7. Carefully open the inner package. Fold open the top flap, then the bottom and sides (Figure 2). Take care not to touch the inner surface of the package or the gloves. The inner surface of the package is considered sterile. The outer 1-inch border of the inner package is considered contaminated. The sterile gloves are exposed with the cuff end closest to the nurse. LWBK545_C04_p123-150.qxd 8/5/10 3:40 PM Page 141 Aptara Inc 141 CHAPTER 4 Asepsis and Infection Control ACTION FIGURE 1. Pulling top layer of outside wrapper back. R AT I O N A L E FIGURE 2. Folding back side flaps. 8. With the thumb and forefinger of the nondominant hand, grasp the folded cuff of the glove for the dominant hand, touching only the exposed inside of the glove (Figure 3). Unsterile hand touches only inside of glove. Outside remains sterile. 9. Keeping the hands above the waistline, lift and hold the glove up and off the inner package with fingers down (Figure 4). Be careful it does not touch any unsterile object. Glove is contaminated if it touches any unsterile objects. FIGURE 3. Grasping cuff of glove for dominant hand. FIGURE 4. Lifting glove from package. 10. Carefully insert dominant hand palm up into glove (Figure 5) and pull glove on. Leave the cuff folded until the opposite hand is gloved. Attempting to turn upward with unsterile hand may result in contamination of sterile glove. 11. Hold the thumb of the gloved hand outward. Place the fingers of the gloved hand inside the cuff of the remaining glove (Figure 6). Lift it from the wrapper, taking care not to touch anything with the gloves or hands. Thumb is less likely to become contaminated if held outward. Sterile surface touching sterile surface prevents contamination. 12. Carefully insert nondominant hand into glove. Pull the glove on, taking care that the skin does not touch any of the outer surfaces of the gloves. Sterile surface touching sterile surface prevents contamination. (continued) LWBK545_C04_p123-150.qxd 8/5/10 3:40 PM Page 142 Aptara Inc 142 UNIT I 4-6 Actions Basic to Nursing Care Putting on Sterile Gloves and Removing Soiled Gloves ACTION FIGURE 5. Inserting dominant hand into glove. continued R AT I O N A L E FIGURE 6. Sliding fingers under cuff of glove for nondominant hand. 13. Slide the fingers of one hand under the cuff of the other and fully extend the cuff down the arm, touching only the sterile outside of the glove (Figure 7). Repeat for the remaining hand. Sterile surface touching sterile surface prevents contamination. 14. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas (Figure 8). Sterile surface touching sterile surface prevents contamination. FIGURE 7. Sliding fingers of one hand under cuff of other hand FIGURE 8. Adjusting gloves as necessary. and extending cuff down the arm. 15. Continue with procedure as indicated. Removing Soiled Gloves 16. Use dominant hand to grasp the opposite glove near cuff end on the outside exposed area. Remove it by pulling it off, inverting it as it is pulled, keeping the contaminated area on the inside (Figure 9). Hold the removed glove in the remaining gloved hand. Contaminated area does not come in contact with hands or wrists. 17. Slide fingers of ungloved hand between the remaining glove and the wrist (Figure 10). Take care to avoid touching the outside surface of the glove. Remove it by pulling it off, inverting it as it is pulled, keeping the contaminated area on the inside, and securing the first glove inside the second (Figure 11). Contaminated area does not come in contact with hands or wrists. LWBK545_C04_p123-150.qxd 8/5/10 3:40 PM Page 143 Aptara Inc CHAPTER 4 Asepsis and Infection Control ACTION 143 R AT I O N A L E FIGURE 9. Inverting glove as it is removed. FIGURE 10. Sliding fingers of ungloved hand inside remaining glove. FIGURE 11. Inverting glove as it is removed, securing first glove inside it. 18. Discard gloves in appropriate container. Remove additional PPE, if used. Perform hand hygiene. Proper disposal and removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. EVALUATION The expected outcome is met when gloves are applied and removed without contamination. Other expected outcomes are met when the patient remains free of exposure to potential infection-causing microorganisms, and does not exhibit signs and symptoms of a latex-allergy response. DOCUMENTATION It is not usually necessary to document the addition of sterile items to a sterile field. However, document the use of sterile technique for any procedure performed using sterile technique. UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Contamination occurs during application of the sterile gloves: Discard gloves and open new package of sterile gloves. A hole or tear is noticed in one of the gloves: Discard gloves and open a new package of sterile gloves. A hole or tear is noticed in one of the gloves during the procedure: Stop procedure. Remove damaged gloves. Wash hands or perform hand hygiene (depending on whether soiled or not) and put on new sterile gloves. The patient touches the nurse’s hands or the sterile field: If the patient touches your hands and nothing else, you may remove the contaminated gloves and put on new, sterile gloves. It is always a good idea to bring two pairs of sterile gloves into the room, depending on facility policy. If the patient touches the sterile field, discard the supplies and prepare a new sterile field. If the patient is confused, have someone assist you by holding the patient’s hands or reinforcing what is happening. Patient has a latex allergy: Obtain latex-free sterile gloves. 144 UNIT I Actions Basic to Nursing Care 4-7 Using Personal Protective Equipment Personal protective equipment refers to specialized clothing or equipment worn by an employee for protection against infectious materials. PPE is used in healthcare settings to improve personnel safety in the healthcare environment through the appropriate use of PPE (CDC, 2004a). This equipment includes clean (unsterile) and sterile gloves, impervious gowns/aprons, surgical and high-efficiency particulate air (HEPA) masks, N95 disposable masks, face shields, and protective eyewear/goggles. Understanding the potential contamination hazards related to the patient’s diagnosis and condition and the institutional policies governing PPE is very important. The type of PPE used will vary based on the type of exposure anticipated and category of precautions: Standard Precautions and Transmission-Based Precautions, including Contact, Droplet, or Airborne Precautions. It is the nurse’s responsibility to enforce the proper wearing of PPE during patient care for members of the healthcare team. Refer to Fundamentals Review 4-4 and Fundamentals Review 4-5 for a summary of CDC-recommended practices for Standard and Transmission-Based Precautions. Box 4-1 provides Guidelines for Effective Use of PPE. BOX 4-1 GUIDELINES FOR EFFECTIVE USE OF PPE Put on PPE before contact with the patient, preferably before entering the patient’s room. Choose appropriate PPE based on the type of exposure anticipated and category of isolation precautions. When wearing gloves, work from ‘clean’ areas to ‘dirty’ ones. Touch as few surfaces and items with your PPE as possible. Avoid touching or adjusting other PPE. Keep gloved hands away from your face. If gloves become torn or heavily soiled, remove and replace. Perform hand hygiene before putting on the new gloves. Personal glasses are not a substitute for goggles. (Adapted from Centers for Disease Control and Prevention (CDC). (2007e). Personal protective equipment for healthcare personnel. Excerpted from guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Available at www.cdec.gov/mcidod/dhqp/pdf/guidelines/Isolation2007.pdf. Accessed June 12, 2009.) EQUIPMENT Gloves Mask (surgical or particulate respirator) Impervious gown Protective eyewear (does not include eyeglasses) Equipment for PPE may vary depending on facility policy. ASSESSMENT Assess the situation to determine the necessity for PPE. In addition, check the patient’s chart for information about a suspected or diagnosed infection or communicable disease. Determine the possibility of exposure to blood and body fluids and identify the necessary equipment to prevent exposure. Refer to the infection control manual provided by your facility. NURSING DIAGNOSIS Determine the related factors for the nursing diagnoses based on the patient’s current status. Appropriate nursing diagnoses may include: Risk for Infection Impaired Skin Integrity Ineffective Protection Deficient Knowledge Diarrhea Bowel Incontinence OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when using PPE is that the transmission of microorganisms is prevented. Other outcomes that may be appropriate include the following: patient and staff remain free of exposure to potentially infectious microorganisms; and patient verbalizes information about the rationale for use of PPE. LWBK545_C04_p123-150.qxd 8/5/10 3:41 PM Page 145 Aptara Inc CHAPTER 4 Asepsis and Infection Control 145 IMPLEMENTATION ACTION R AT I O N A L E 1. Check medical record and nursing plan of care for type of precautions and review precautions in infection control manual. Mode of transmission of organism determines type of precautions required. 2. Plan nursing activities before entering patient’s room. Organization facilitates performance of task and adherence to precautions. 3. Perform hand hygiene. Hand hygiene prevents the spread of microorganisms. 4. Provide instruction about precautions to patient, family members, and visitors. Explanation encourages cooperation of patient and family and reduces apprehension about precaution procedures. 5. Put on gown, gloves, mask, and protective eyewear, based on the type of exposure anticipated and category of isolation precautions. Use of PPE interrupts chain of infection and protects patient and nurse. Gown should protect entire uniform. Gloves protect hands and wrists from microorganisms. Masks protect nurse or patient from droplet nuclei and large-particle aerosols. Eyewear protects mucous membranes in the eye from splashes. a. Put on the gown, with the opening in the back. Tie gown securely at neck and waist (Figure 1). Gown should fully cover the torso from the neck to knees, arms to the end of wrists, and wrap around the back. b. Put on the mask or respirator over your nose, mouth, and chin (Figure 2). Secure ties or elastic bands at the middle of the head and neck. If respirator is used, perform a fit check. Inhale; the respirator should collapse. Exhale; air should not leak out. Masks protect nurse or patient from droplet nuclei and largeparticle aerosols. A mask must fit securely to provide protection. c. Put on goggles (Figure 3). Place over eyes and adjust to fit. Alternately, a face shield could be used to take the place of the mask and goggles (Figure 4). Eyewear protects mucous membranes in the eye from splashes. Must fit securely to provide protection. d. Put on clean disposable gloves. Extend gloves to cover the cuffs of the gown (Figure 5). Gloves protect hands and wrists from microorganisms. FIGURE 1. Tying gown at neck and waist. FIGURE 2. Applying mask applied over nose, mouth, and chin. (continued) LWBK545_C04_p123-150.qxd 8/5/10 3:41 PM Page 146 Aptara Inc 146 UNIT I 4-7 Actions Basic to Nursing Care Using Personal Protective Equipment ACTION FIGURE 3. Putting on goggles. continued R AT I O N A L E FIGURE 4. Putting on face shield. FIGURE 5. Putting on gloves, ensuring gloves cover gown cuffs. 6. Identify the patient. Explain the procedure to the patient. Continue with patient care as appropriate. Patient identification validates the correct patient and correct procedure. Discussion and explanation help allay anxiety and prepare the patient for what to expect. Remove PPE 7. Remove PPE: Except for respirator, remove PPE at the doorway or in an anteroom. Remove respirator after leaving the patient room and closing door. Proper removal prevents contact with and the spread of microorganisms. Outside front of equipment is considered contaminated. The inside, outside back, ties on head and back, are considered clean, which are areas of PPE that are not likely to have been in contact with infectious organisms. a. If impervious gown has been tied in front of the body at the waistline, untie waist strings before removing gloves. Front of gown, including waist strings, are contaminated. If tied in front of body, the ties must be untied before removing gloves. b. Grasp the outside of one glove with the opposite gloved hand and peel off, turning the glove inside out as you pull it off (Figure 6). Hold the removed glove in the remaining gloved hand. Outside of gloves are contaminated. c. Slide fingers of ungloved hand under the remaining glove at the wrist, taking care not to touch the outer surface of the glove (Figure 7). Ungloved hand is clean and should not touch contaminated areas. d. Peel off the glove over the first glove, containing the one glove inside the other (Figure 8). Discard in appropriate container. Proper disposal prevents transmission of microorganisms. LWBK545_C04_p123-150.qxd 8/5/10 3:41 PM Page 147 Aptara Inc CHAPTER 4 Asepsis and Infection Control ACTION 147 R AT I O N A L E e. To remove the goggles or face shield: Handle by the headband or ear pieces (Figure 9). Lift away from the face. Place in designated receptacle for reprocessing or in an appropriate waste container. Outside of goggles or face shield is contaminated. Handling by headband or ear pieces and lifting away from face prevents transmission of microorganisms. Proper disposal prevents transmission of microorganisms. f. To remove gown: Unfasten ties, if at the neck and back. Allow the gown to fall away from shoulders. Touching only the inside of the gown, pull away from the torso. Keeping hands on the inner surface of the gown, pull from arms. Turn gown inside out. Fold or roll into a bundle and discard. Gown front and sleeves are contaminated. Touching only the inside of the gown and pulling it away from the torso prevents transmission of microorganisms. Proper disposal prevents transmission of microorganisms. g. To remove mask or respirator: Grasp the neck ties or elastic, then top ties or elastic and remove. Take care to avoid touching front of mask or respirator. Discard in waste container. If using a respirator, save for future use in the designated area. Front of mask or respirator is contaminated; Do Not Touch. Not touching the front and proper disposal prevent transmission of microorganisms. FIGURE 6. Grasping the outside of one glove and peeling off. FIGURE 7. Sliding fingers of ungloved hand under the remaining glove at the wrist. FIGURE 8. Pulling glove off the hand and over the other glove. FIGURE 9. Removing goggles by grasping ear pieces. (continued) LWBK545_C04_p123-150.qxd 8/5/10 3:41 PM Page 148 Aptara Inc 148 UNIT I 4-7 Actions Basic to Nursing Care Using Personal Protective Equipment ACTION continued R AT I O N A L E 8. Perform hand hygiene immediately after removing all PPE. Hand hygiene prevents spread of microorganisms. EVALUATION The expected outcome is met when the transmission of microorganisms is prevented; the patient and staff remain free from exposure to potentially infectious microorganisms; and the patient verbalizes an understanding about the rationale for use of PPE. DOCUMENTATION It is not usually necessary to document the use of specific articles of PPE or each application of PPE. However, document the implementation and continuation of specific transmission-based precautions as part of the patient’s care. UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS You did not realize the need for protective equipment at beginning of task: Stop task and obtain appropriate protective wear. You are accidentally exposed to blood and body fluids: Stop task and immediately follow agency protocol for exposure, including reporting the exposure. ENHANCE YOUR UNDERSTANDING Integrated Case Study Connection The case studies in the back of the book are designed to focus on integrating concepts. Refer to the following case studies to enhance your understanding of the concepts related to the skills in this chapter. Basic Case Studies: Tiffany Jones, page 954; John Willis, page 959 Intermediate Case Studies: Tula Stillwater, page 972; Gwen Galloway, page 980; George Patel, page 981 Developing Critical Thinking Skills 1. While preparing the sterile table in the cardiac catheterization lab for Mr. Wilson, you realize that a sterile bowl is missing. How can you obtain a sterile bowl? 2. While you are putting on sterile gloves in preparation for an indwelling urinary catheter insertion, your patient, Sheri Lawrence, moves her leg. You do not think that Sheri’s leg touched the glove, but you are not positive. What should you do? 3. Edgar Barowski’s son is visiting and asks you why the masks that are outside Edgar’s room are different from the ones that people wear in the operating room. What should you tell Edgar’s son? Suggested Answers for Developing Critical Thinking Skills 1. You should call for or ask another staff member to obtain the bowl. Never walk away from or turn your back on a sterile field. This prevents possible contamination while the field is out of your view. 2. You should change gloves. Only a sterile object can touch another sterile object. Unsterile touching sterile means contamination has occurred. Consider an object contaminated if you have any doubt about its sterility. 3. You should explain the rationale for transmissionbased precautions, including specific information about airborne precautions. Airborne precautions are used for patients who have infections that spread through the air, such as tuberculosis, varicella (chicken pox), rubeola (measles), and possibly SARS. Place patient in private room that has monitored negative air pressure in relation to surrounding areas, 6 to 12 air changes per hour, and appropriate discharge of air outside or monitored filtration if air is recirculated. Keep door closed and patient in room. Respiratory protection is used when entering room of patient with known or suspected tuberculosis.