1. Surgical Asepsis
Chapter 20

2. Assigned Reading
Chapter 20, volumes one and two

3. Principles of Surgical Asepsis
Touching one sterile item with another sterile item
Touching one sterile item with a non-sterile item yields it contaminated
Partially unwrapped sterile package is contaminated
If a question arises about sterility it is contaminated
A commercially packaged sterile item is not considered sterile past its recommended expiration date
Once a sterile item is opened it is only a matter of time before it becomes contaminated- set up immediately before using
A sterile wrapper, if it becomes wet, wicks microorganisms from its supporting surface, causing contamination

4. Principles of Surgical Asepsis (cont.)
Any opened sterile item or sterile area is considered contaminated if it is left unattended (in OR and Delivery, covered with a sterile field)
Coughing, sneezing, or excessive talking over a sterile field causes contamination
Reaching across an area that contains sterile equipment has a high potential for causing contamination and therefore is avoided
Sterile items that are located or lowered below the waist are considered contaminated
Avoid use of one inch perimeter margin of a sterile field

5. Sterilization
Physical & chemical techniques that destroy all microorganisms and spores

6. Physical Sterilization
Radiation- (generally combined with other means). Effective for TB. Home means includes sunlight
Boiling (212F X 15 minutes)
Free-flowing steam (212F heat vapors)
Dry heat- Similar to baking in oven ( F X 3 hours)
Steam under pressure-most dependable. Autoclave method. Temperature over 212F. Pressure allows for hotter temperature than boiling. Heat sensitive tapes may be used.

7. Chemical Sterilization
Peracetic Acid-quick and reliable for sterilizing heat sensitive instruments. 30 minutes
Ethylene Oxide Gas-destroys microorganisms in 3 hours. Must air following (5 days) to remove traces of gas (could cause chemical burns)

8. Surgical Asepsis Includes: Creation of a sterile environment
Use of sterile equipment/supplies/solutions
Sterilization of reusable supplies
Surgical hand scrub
Surgical attire if in OR
Sterile gloves
Sterile field
Use of sterile technique

9. Other Examples of Sterile Supplies
Dressing supplies (gauze, kerlix)
Injection supplies (needles)
IV catheters
Sutures
Foley catheters

10. Surgical Asepsis Donning sterile gloves-Skill
Donning sterile gown (during surgery and delivery of infants). Apply mask and hair cover first, then gown and last gloves. Gown will be wrapped from central supply with inside facing towards you so you can grasp and put on without contaminating outside of gown which must remain sterile.

11. Sterile Technique Used for . . . Operating room Dressings
Insertion of Foley catheters
Assisting physicians with procedures

12. Gloves and Sterile Fields

13. Creating a Sterile Field
A work area free of microorganisms
Formed using the inner surface of a cloth or paper wrapper that holds sterile items
The field enlarges the area where sterile equipment or supplies are placed
Set the field up immediately before planning to use

14. Creating a Sterile Field Skill
Inspect the work area to determine the cleanliness and orderliness of the surface on which you will work
Obtain supplies
Check the package to assure it is sealed and that the date has not expired
Explain what you will do to the patient

15. Perform handwashing or hand antisepsis
Open the barrier/field and lift one inch from the edge straight up from the wrapper, keeping the long edge from touching the work station
Keep above waist level
Two ways to open the sterile field:
Long way or short way are both acceptable as long as contamination does not occur

16. Without shaking, lie the sterile field onto the work station without touching the sterile side of the field (keep your hands on the underside of the field)

17. Donning Sterile Gloves
Select a package of sterile gloves of the appropriate size
Remove unnecessary items from the overbed table
Perform handwashing or alcohol-rub antisepsis
Open the outer wrapper of the gloves
Carefully open the inner package and expose the sterile glove with the cuff end closest to you

19. Pick up one glove at the folded edge of the cuff using your thumb and fingers
Insert your fingers while pulling and stretching the glove over your hand, taking care not to touch the outside of the glove to anything that is nonsterile
Unfold the cuff so the glove extends above the wrist, but touch only the surface that will be in direct contact with the skin

20. Insert the gloved hand beneath the sterile folded edge of the remaining glove
Insert the fingers within the second glove while pulling and stretching it over the hand
May use gloved hands to fix fingers
Take care to avoid touching anything that is not sterile
Maintain your gloved hands at or above waist level

22. Disposal of Contaminated Gloves
Handout
Grasp outside of one cuff with other gloved hand; avoid touching wrist.
Pull glove off, turning it inside out and discard.
See handout

23. Nursing Implications: Nursing Diagnoses
Risk for infection
Risk for Infection Transmission
Ineffective Protection
Delayed Surgical Recovery
Deficient Knowledge

24. Lab Practice for Sterile Gloves (pair)
Lab Practice for Opening a Sterile Field

25. Dressings and Wound Management
Combination of Chapter 20 –Principles of Surgical Asepsis and Chapter 34 – Wound Care
Assigned readings-chapter 20 and chapter 34, volumes one and two

26. Goal of Wound Management
To reapproximate the tissue to restore its integrity

27. Wound Management Dressings Drains Sutures and Staples
Bandages and Binders
Irrigations

28. PURPOSES OF A DRESSING
Keep the wound clean (use sterile supplies and sterile technique)
Absorbing drainage (various dressing materials)
Controlling bleeding (pressure dressings, wraps)
Protecting the wound from further injury (i.e. duoderm)
Holding medication in place
Maintaining a moist environment (hydrocolloid dressings, saline dressings, Alldress system)

29. TYPES OF DRESSINGS
Gauze dressings-highly absorbent to cover fresh wounds that are likely to bleed or exude drainage (woven cloth fibers). Allows air flow to wound. Can debride new granulation, may need to moisten with NS if adhered to prevent debridement.
Transparent dressings-Allows the nurse to assess the wound; commonly used to cover peripheral and central IV insertion sites
Hydrocolloid dressing-They keep wounds moist because they heal more quickly in a wet environment. Self adhesive. May stay on 1 week.

30. Dressing Supplies for Typical Surgical Dressing
2 X 2 gauze
4 X 4 gauze (come single packs and multipacks)
Fluffs
Drain sponges
ABD pad (Combine dressing)
Rolled gauze- Kerlix or Kling
Some agency have commercially packaged dressing kits (expensive)
Solution to clean the wound (need to lip the containers to remove contamination)
Sterile field (barrier)
Sterile gloves
Unsterile gloves to remove the old dressing
Bag/receptacle for disposal of old dressing

31. One Swipe per Gauze- BUNCH UP 4 X 4

32. TYPES OF DRAINS
Purpose of drain is to remove blood and cellular debris
Open drains-flexible tubes that provide a pathway for drainage toward the dressing. Called penrose and often used for abdominal surgery or kidney surgery.
Drainage occurs by passive gravity & by capillary action (movement of a liquid at the point of contact with a solid, which would be the gauze)
Closed drains-Hemovac and Jackson Pratt to pull fluid by creating a vacuum or negative pressure. Hemovac often used for orthopedic surgery.
T-tube often used for gallbladder surgery or biliary surgery.

33. Closed drains pull fluid by creating a vacuum or negative pressure
Closed drains pull fluid by creating a vacuum or negative pressure. Open the vent on the receptacle, squeeze the drainage collection chamber and then cap the vent.

34. Cleaning Around Drains
Circular motion
Start closest to the drain and go outward
Drains are often located beside a surgical wound, rather than within the wound line.
After cleaning around the drain, a pre-cut drain sponge is placed around the drain.
Expect more drainage from the exit point of an open drain, more gauze needed at this spot.

35. Types of Dressings
Dry Sterile Dressing (DSD)-clean wound and apply dry gauze, dressing material
Newer recommendations may include clean technique rather than sterile technique. Follow agency protocols. For lab pass offs, will do sterile technique with a penrose drain in place.
Wet to dry dressing-cover wound only with wet dressing then top with a dry gauze dressing; now expect wet to moist dressings rather than wet to dry
Packing-follow medical orders for type, length, width and if packing is medicated packing or gauze packing (can be used for tunneling-use Q-tips to pack or sterile forceps)

36. Dressing Change Follow medical orders for time, frequency
Often “initial” (original) dressing is done by physician

37. Other Orders for Dressing Change
Reinforce dressing- add to existing dressing

38. Assessing Wound Drainage
Amount and Color:
Serous-clear, watery, thin, may be straw colored
Sanguineous-bright red, active bleeding
Serosanguineous-pale red, mixture of clear & red fluid, more watery than sanquinous
Purulent-thick yellow, green, tan or brown

39. Wound Complications Dehiscence-reopening of surgical wound
Evisceration-spilling of abdominal contents-many factors; usually follows dehiscence, abscess formation (should evisceration occur, cover with normal saline gauze to keep moist)
Infection/abscess-associated with bowel/appendix-wound expect to see open wound

40. Techniques to Keep a Dressing in Place
Tape (different types of tape, dependent on patient’s tolerance/allergies
Montgomery straps- often used if need frequent dressing changes
Netting (comes in several different sizes)

42. To Remove Tape
Remove tape by pulling it toward the wound- prevents separation of wound

44. Documentation of Dressing Change
Describe the drainage on old dressing
Assess and describe the wound, measure
Clean the wound (and drain site if applicable)
Apply dressing material
Document your assessment data, actions and patient response (DAR)

45. NURSING IMPLICATIONS: NURSING DIAGNOSES
Acute Pain
Impaired Skin Integrity
Ineffective Tissue Perfusion
Impaired Tissue integrity
Risk for Infection

46. BANDAGES AND BINDERS
Bandage-Strip or roll of cloth wrapped around a body part (example: Ace bandage)
Binder-Type of bandage generally applied to a particular body part
Binders and bandages hold dressings in place when tape cannot be used or the dressing is large
Supporting the area around a wound or injury to reduce pain
Limiting movement in the wound area to promote healing

47. Ace Bandages Wrap from distal to proximal direction Avoid gaps
Equal tension
Free of wrinkles
Remove twice a day
Check CSM-color, sensation, movement

48. Irrigations Purpose: Rinse out cellular debris
Remove purulent drainage
Bathe tissue with medications
Keep area moist

49. Types of Irrigations Clean technique: Sterile technique: Eyes Ears
Vagina
Feeding tubes
Nasogastric tubes
Sterile technique:
Wounds
Bladder

50. Irrigations Kits Solution Padding Basin Dressing Supplies
Date and time all containers
Sterile solutions expire 24 hours after opening
Irrigations done with smaller needle rather than irrigation syringe in kit

51. Lab Practice Personal Dressing Kits- keep all supplies
Lab demonstration by instructor
Step by Step
Set up disposal bag for old dressing
Apply unsterile (clean) gloves and remove old dressing. (If dressing sticks, apply saline and remove with clean glove). Assess wound and drainage, discard dressing, remove and discard gloves.
Perform hand hygiene
Set up field
Apply items to field (only add one sterile glove, other will be put on from bedside)
Lip solution (i.e. normal saline) to clean the wound
Apply one sterile glove that was not on the field
Clean incision first using one of the appropriate cleaning techniques (hold cleaning container with non gloved hand). Bunch up the 4 x4 for cleaning the incision.
Clean incision before drain site
With gloved hand go into field and apply second glove
Apply dressing (gauze, drain sponge, gauze on top of drain sponge, abd. pads)
Secure dressing with tape (make a tab for easy removal)

55. DEBRIDEMENT – this is a review
Sharp debridement-Removal of necrotic tissue with a sterile scissors.
Enzymatic debridement-Use of a topical chemical substance that breakdown and liquefy wound debris.
Autolytic debridement-Painless, natural physiologic process that allows the body’s enzymes to soften, liquefy, and release devitalized tissue
Mechanical debridement-Use of wet-dry dressing to remove debris

56. FACTORS WHICH AFFECT WOUND HEALING
Type of wound injury
Expanse or depth of wound
Quality of circulation
Amount of wound debris
Presence of infection
Status of the client’s health

57. HEALING- review
First Intention Healing-Primary intention is a reparative process in which the wound edges are directly next to each other.
Second Intention Healing-The wound edges are widely separated, leading to a more time-consuming and complex reparative process.
Third Intention Healing-The wound edges are widely separated and are later brought together with some type of closure material.

59. Lab Practice Personal Dressing Kits- keep all supplies
Lab demonstration by instructor
Step by Step
Set up disposal bag for old dressing
Apply unsterile (clean) gloves and remove old dressing. (If dressing sticks, apply saline and remove with clean glove). Assess wound and drainage, discard dressing, remove and discard gloves.
Perform hand hygiene
Set up field
Apply items to field (only add one sterile glove, other will be put on from bedside)
Lip solution (i.e. normal saline) to clean the wound
Apply one sterile glove that was not on the field
Clean incision first using one of the appropriate cleaning techniques (hold cleaning container with non gloved hand). Bunch up the 4 x4 for cleaning the incision.
Clean incision before drain site
With gloved hand go into field and apply second glove
Apply dressing (gauze, drain sponge, gauze on top of drain sponge, abd. pads)
Secure dressing with tape (make a tab for easy removal)