When preparing to pour a sterile solution you should place the bowl on the edge of the sterile field?

3-6. OPENING AND POURING STERILE LIQUIDS

Sterile liquids are necessary for many procedures requiring sterile technique. Use the following procedures to open bottles containing a sterile liquid and to pour the liquids into a sterile container.

a. Lift or unscrew the cap. Do not touch bottle rim and inside cap, as these items are considered sterile. As you remove the cap, listen for a vacuum release sound. If there is no vacuum release sound, assume that the liquid is not sterile and get another bottle of the liquid to use instead.

b. Hold the cap in your hand or rest the cap upside down on table (not on sterile field since the outside of the cap is contaminated) so that the inside of the cap does not become contaminated. If the cap becomes contaminated, it cannot be used to reseal the bottle of sterile liquid and the left over portion of the sterile liquid must be discarded.

c. Glove your nondominant hand.

(1) Make sure glove package has not been contaminated (torn, and so forth) and that gloves are the proper size.

(2) Perform a patient care handwash, if you have not already done so.

(3) Place the package on a clean, dry surface.

(4) Peel back the outer wrapper.

(5) Remove the inner package and place it so that the end marked "cuff" is toward you.

(6) Grasp lower corner and open the package to a flat position.

(7) Grasp lower corners of the package and pull to the side in order to expose the cuffs.

(8) Grasp the cuff of the glove on the same side as your nondominate hand with your dominate hand. (figure 3-8).

Figure 3-8. Grasp cuff.

(9) Remove the glove from the wrapper, step back, and insert your nondominate hand into the glove (figure 3-9).

Figure 3-9. Hand in glove.

d. Hold bottle in your ungloved hand with label against your palm. This protects the label from dripping solution. Also a clean label can be read easily.

e. If the bottle was opened previously, pour a small amount of liquid into a waste container, usually an emesis basin. Prepouring will cleanse the lid of the bottle. The container should not be inside the sterile field.

f. Pick up the container into which the liquid is to be poured with your gloved hand and step back from the sterile field. This is done to keep any liquid from dropping onto the sterile field. If a sterile field becomes wet, consider it to be contaminated.

g. Hold the bottle about 6 inches above the container into which the liquid is being poured and pour the liquid slowly in a steady stream into the sterile container. Pouring slowly in a steady stream avoids splashing.

(1) Do not touch the bottle lip against the container. If the lip of the bottle touches the container, the container will not be sterile.

(2) Do not allow the bottle to pass over the sterile field. If the bottle passes over any part of the sterile field, then that part of the field is considered contaminated, because a microscopic organism could have fallen from the bottle or your hand onto the field.

h. Replace the container onto the sterile field.

i. Replace the cap securely on the bottle. If the cap or rim of the bottle becomes contaminated, discard the bottle.

j. Remove the sterile glove by grasping the portion of the glove over the heel of the hand and pulling the glove off. Discard the glove in an appropriate container.

k. Write the date and time and your initials on the bottle label.

l. Return the bottle to the storage area. (NOTE: Local SOP may require that you discard the bottle rather than reusing it.) Vacuum-packed sterile liquids can normally be used for 24 hours if the bottle is resealed. If your ungloved hand or other contaminated object touches the neck of the bottle, inside the bottle cap, the bottle rim, or the lip of the cap, the rim or cap is considered contaminated and you must discard the bottle.

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3-7. ASSISTING WITH THE WITHDRAWAL OF STERILE SOLUTION FROM A VIAL

Some sterile liquids that are used as medications for injection come in small bottles with rubber tops. These tops can be pierced with a sterile needle in order to withdraw the sterile contents. When performing this procedure, you will be assisting a physician or other medical personnel who is wearing sterile gloves and cannot touch the outside of the vial because the vial is contaminated. You, however, will not be gloved. Follow the procedures given below.

a. Obtain a correct vial of solution. Check the bottle against the physician's orders to verify that the solution is correct (correct name, dosage, and route).

b. Clean the vial stopper with an alcohol swab.

c. Hold the vial firmly with the label up so that the person with the sterile gloved hands can verify that the solution is the proper one. The gloved person then:

(1) Pulls the plunger of the syringe to the amount of solution required.

(2) Inserts the needle through center of rubber stopper.

(3) Pushes the plunger into the syringe to increase air pressure inside vial (figure 3-10).

Figure 3-10. Withdraw sterile fluid.

(4) Pulls plunger out to somewhat more than the prescribed level.

(5) Withdraws the needle with a quick straight pull. (If the needle touches the outside of the vial, then the needle is contaminated and the entire procedure must be done again.)

d. Discard or store vial in accordance with local SOP.

NOTE: Withdrawing fluid from an ampule is accomplished in basically the same

manner.

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The Brookside Associates Medical Education Division develops and distributes medical information that may be useful to medical professionals and those in training to become medical professionals. This website is privately-held and not connected to any governmental agency. The views expressed here are those of the authors, and unless otherwise noted, do not necessarily reflect the views of the Brookside Associates, Ltd., or any governmental or private organizations. All writings, discussions, and publications on this website are unclassified.

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EXERCISES, LESSON 3

INSTRUCTIONS: Answer the following exercises by marking the lettered response that best answers the exercise, by completing the incomplete statement, or by writing the answer in the space provided at the end of the exercise. After you have completed all of these exercises, turn to "Solutions to Exercises" at the end of the lesson and check your answers. For each exercise answered incorrectly, reread the material referenced with the solution.

1. Sterile technique is to be used in any procedure involving:

a. An open wound.

b. Entering a sterile body cavity.

c. Cutting or puncturing the skin.

d. Choices a and c.

e. Choices a, b, and c.

2. Which one of the following is not one of the basic steps in sterile technique?

a. Set up equipment in a sterile room.

b. Wash your hands thoroughly before beginning a sterile procedure.

c. Keep sterile objects sterile while preparing for a sterile procedure.

3. The sterile field should be established on a field that is:

a. Clean.

b. Dry.

c. Flat.

d. Free from drafts.

e. Choices a, b, and c above.

f. Choices a, b, c, and d above.

4. The preferred method for creating a sterile field involves:

a. Wiping a clean table with sterile povidone-iodine solution.

b. Wiping a clean table with 70 percent isopropyl alcohol.

c. Opening a double-wrapped sterile package on a table.

d. Covering a table with sterile drapes.

5. You have created a sterile field using the inside wrapper of a double-wrapped sterile package. What are the boundaries of the area that is considered to be sterile?

a. The edge of the sterile wrapper.

b. One inch beyond the edges of the sterile inside wrapper.

c. One inch inside the edges of the sterile inside wrapper.

6. Which one of the following is not a rule for opening a sterile liquid when a sterile field is in use?

a. Do not touch the inside of the cap.

b. Place the cap upside down on the sterile field.

c. Do not touch the rim of the bottle.

d. Listen for a vacuum sound when opening the bottle.

7. You are assisting a person who is sterile to withdraw sterile medication into a sterile needle and syringe. Your job will be to hold the:

a. Bottle of medication.

b. Needle and syringe.

c. Patient's skin taut.

Check Your Answers on Next Page

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4-2. DRESSING MATERIALS

Various types of dressing materials can be used when applying or changing a dressing. The following are those most frequently used.

a. Coarse Mesh Gauze Sponge. Coarse mesh gauze sponge

(figure 4-1) is commonly used as an intermediate layer in many dressings. It is available in several sizes, but the ones used routinely are 2 x 2 inches, 4 x 4 inches, and 4 x 8 inches.

Figure 4-1. Mesh gauze.

b. Abdominal Pad. The abdominal (ABD) pad (figure 4-2) is a large, thick, multilayered absorbent dressing. It is used as an intermediate layer in many dressings. It is primarily used for postoperative abdominal incisions.

Figure 4-2. Abdominal pad.

c. Telfa Pad. The Telfa pad (figure 4-3) is a pad with a plastic-like coating on one side of gauze dressing which prevents the dressing from sticking to the wound.

Figure 4-3. Telfa pad.

d. Petrolatum (Vaseline) Gauze. The petrolatum gauze (figure 4-4) consists of gauze coated with petroleum jelly. It is used to protect tissue from drying, to prevent adherence to the wound, and to create an airtight seal.

Figure 4-4. Petrolatum dressing.

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4-5. REMOVING A SOILED DRESSING

Incisions and wounds that have been sutured will normally have two layers of dressing. One layer consists of gauze pads laid directly over the closed cut. A larger dressing will then be placed over the gauze pads. This second (outer) dressing covers more area than the inner dressing (gauze pads). If the wound is on the arm or leg, the dressings are normally secured with a bandage. If the wound is on the trunk of the body, such as an abdominal wound, the outer dressing is normally secured by tape. In the following example, the sterile dressing being changed covers an abdominal wound.

a. Verify Patient's Identity. Make sure that the patient whose dressing is to be changed is the patient for whom the action was ordered. Ask the patient his name. Also compare the patient's name on the orders with the name listed on the patient's bed card and identification bracelet.

b. Reassure the Patient. Provide privacy if possible by placing a screen or curtain around the patient or by closing the door. Gain the patient's help and confidence by telling him why you are changing the dressing.

c. Wash Hands. Perform a patient care handwash. Handwashing may not always be possible in a field situation; however, every effort should be made to provide handwashing facilities.

d. Obtain Necessary Equipment and Supplies. The following items are normally used.

(1) Dressings--4-in x 4-in (10-cm x 10-cm) and 4-in x

8-in (10-cm x 20-cm) sponges.

(2) Gauze pads (sponges).

(3) Cotton-tipped applicators gauze pads may be used instead.

(4) Tape.

(5) Adhesive solvent.

(6) Basins for adhesive solvent and for normal saline.

(7) Sterile towels (for sterile field).

(8) Gloves.

(9) Scissors.

(10) Sterile forceps.

(11) Saline solution.

(12) Solution basin, if applicable.

(13) Drain, if applicable.

e. Prepare the Patient. Position the patient so that the wound site is easily accessible. Expose the wound area by removing the patient's clothing and/or by folding the bed linens, gown, or pajamas away from the wound area. Do not expose any more of the patient's body than is necessary.

f. Prepare the Work Area.

(1) Clear all items off the bedside stand or the over-the-bed table.

(2) Clean and dry area where the sterile field will be established if needed.

(3) Cut the tape strips to the size that is required to secure the dressing.

(4) Attach one end of each tape strip to an area that can be easily reached.

(5) Pour adhesive solvent into the solvent basin.

(6) Pour the disinfecting solution into a solution basin.

(7) Put on mask and sterile gloves.

g. Remove 0uter Dressing. Do not put pressure on the wound when removing the dressings. Pressure causes pain, additional injury, and interferes with the healing process.

(1) Loosen the ends of the tape attached to the patient's skin (figure 4-5).

Figure 4-5. Removing tape.

(2) Peel ends toward the wound while holding the skin with the other hand. Do not remove tape in a direction away from the wound. If you peel going away from the outer dressing, you will create tension on the wound, which may disrupt the scab or tear the skin.

(3) Once the tape has been separated from the skin, remove the dressings.

(4) Check the dressings for odor, discoloration, and drainage.

(5) Discard the outer dressing in a contaminated waste container.

h. Prepare to Remove Inner Dressings.

(1) Wash your hands.

(2) Unfold the sterile towels so as to create a sterile field.

(3) Put on sterile gloves and mask.

i. Remove Inner Dressings.

(1) Grasp the edge of the top inner dressing with the forceps and gently roll the dressing off the wound.

(a) Point the tips of the forceps downward.

(b) If the dressing sticks to the wound, moisten the dressing with sterile water to soften surface of wound. If moistening the dressing does not loosen the dressing, check with your supervisor.

(2) Check the dressings for odor, color, and drainage. Report any abnormal wound drainage to your supervisor.

(3) Discard the dressing into a contaminated waste container without touching the contaminated side of the dressing to yourself or to any surface.

(4) Continue until all of the inner dressings have been removed and discarded.

(5) Drop forceps onto the glove wrap.

j. Remove the Adhesive. Gently rub a solvent-soaked cotton-tipped applicator or gauze pad over the adhesive around the wound. Removing the adhesive that sticks to the skin reduces the chance for skin breakdown (irritation) and adds to the patient's comfort.

k. Observe Skin and Wound Site. Observe the skin for signs of irritation (redness, rash, and/or swelling). Inspect the wound for:

(1) Redness.

(2) Swelling.

(3) Pus (usually yellow fluid; may be blood-tinged, greenish, or brown).

(4) Putrid (bad) odor.

(5) Unusual color.

(6) Condition of suture (joining of edges of wound).

(7) Condition of drains.

(8) Healing.

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4-6. CLEANSING A WOUND

Cleanse the wound if order indicates. Dip each cotton-tipped applicator or gauze sponge into a saline solution before using it to clean the wound. The cleansing strokes are different for linear wounds than for circular wounds.

a. Cleansing a Linear Wound. The steps for cleansing a linear wound are shown in figure 4-6.

Figure 4-6. Linear wound.

(1) Stroke 1. Swab (wipe) the area directly over the wound with a single stroke. Discard the applicator (sponge) into the container for contaminated wastes.

(2) Stroke 2. On the patient's right side, swab (wipe) the area next to the wound with a single stroke. Discard the applicator (sponge).

(3) Stroke 3. On the patient's left side, swab (wipe) the area next to the wound with a single stroke. Discard the applicator (sponge).

(4) Stroke 4. On the patient's right side, swab (wipe) the area next to the second stroke with a single stroke. Discard the applicator (sponge).

(5) Stroke 5. On the patient's left side, swab (wipe) the area next to the third stroke with a single stroke. Discard the applicator (sponge).

b. Cleansing a Circular Wound. Steps for cleansing a circular or puncture wound are illustrated in figure 4-7.

Figure 4-7. Puncture wound.

(1) Stroke 1. Starting at the center of the wound, swab the area in an outward circular spiral. Then discard the applicator (sponge).

(2) Stroke 2. From the spot where the first stroke ended, continue swabbing (wiping) in an outward circular pattern for about one and one-half revolutions. Then discard the applicator

(sponge).

(3) Stroke 3. From the spot where the second stroke ended, continue swabbing (wiping) in an outward circular pattern for about one and one-half revolutions. Then discard the applicator (sponge).

(4) Stroke 4. From the spot where the third stroke ended, continue swabbing (wiping) in an outward circular pattern for about one and one-half revolutions. Then discard the applicator (sponge). Continue cleaning the area, if needed, until the area around the wound has been cleansed.

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4-10. PROCEDURE FOR IRRIGATING A WOUND

This section gives the procedures for performing a routine wound irrigation using sterile techniques. Irrigation of a wound prior to an operative treatment is discussed in section III.

a. Verify Wound Irrigation Order. Check the Doctor's Orders, Therapeutic Documentation Care Plan, or check with the supervisor to ensure that a wound irrigation is to be performed. Your instructions will specify the type and amount of solution to be used to irrigate the wound.

b. Wash Hands. Perform a patient care handwash.

c. Assemble Equipment and Supplies.

(1) Asepto (bulb-ended) syringe (300 to 500 ml) (figure 4-10). If asepto syringe is not available, use the largest regular syringe stocked.

Figure 4-10. Asepto syringe.

(2) Prescribed irrigating solution (normal saline is usually the preferred irrigation solution).

(3) Emesis basin.

(4) Sterile gloves.

(5) Mask, if needed.

(6) Sterile dressings.

(7) Sterile 4 x 8-inch gauze sponges.

(8) Sterile solution basin.

(9) Protective pad (bedcover).

d. Identify the Patient. Ask the patient his name and check the patient's identification bracelet, bedcard, or other identification. This is done to ensure that you perform the procedure on the correct patient.

e. Explain the Procedure to the Patient. Simply tell the patient what you are going to do and why.

f. Provide Privacy. Place a screen or curtain around the patient, or close the door if the patient is in a room.

g. Position the Patient. Place the patient in a position that provides for maximum exposure of the wound without causing unnecessary exposure of the patient's body. Make sure that there is adequate lighting of the wound area.

h. Position the Protective Pad. Assist the patient, as necessary, to raise his body. Place protective pad directly under the wound. The pad will protect the bedding. After the pad is in place, assist the patient to return to the desired position.

i. Mask, If Needed. A mask may be needed to protect the wound from contamination by microorganisms from your respiratory system. Once you have begun the irrigation, do not touch or adjust your mask since this action could transfer microorganisms from you to the wound or from the wound to you. To don the mask, place the mask on your face and pull the elastic over your head.

j. Remove Soiled Dressings, If Any. See paragraphs 4-5f through k.

k. Wash Hands. Perform a patient care handwash.

l. Prepare Irrigation Equipment.

(1) Check to make sure that you are using the correct solution before you start. If you are using a standard sterile water solution or normal saline solution, check for the date and time on the bottle. Once opened, the water/saline is considered sterile for 24 hours. If the solution has been open for more than 24 hours, discard the solution and obtain another bottle. If you open a new bottle, write the date and time that it was opened on the label.

(2) Open the sterile solution basin on the bedside stand using sterile technique. The opened wrapper will be used as your sterile field.

(3) Pour the prescribed irrigation solution into the basin without contaminating the sterile field.

(4) Open container with the asepto syringe and place it on the sterile field using sterile technique.

(5) Open the 4 x 8-inch sponges, and place them on the sterile field using sterile technique.

(6) Put on the sterile gloves.

(7) Position the sterile solution basin on the sterile drape against the area of the body to be irrigated.

m. Irrigate the Wound.

(1) Position the emesis basin beneath the wound so that the solution used to irrigate the wound will drain into the basin.

(2) Using a 4 x 8 gauze sponge, pat the wound dry. Start at the center of the wound and move outward toward the edges. Then dispose of the pad.

(3) Fill the syringe with irrigating solution.

(a) Grasp the asepto syringe, depress the bulb, and insert the tip of the syringe into the irrigating solution. Release the bulb and allow the syringe to fill.

(b) If you are using a regular syringe, insert the end of the syringe into the irrigating solution and pull back on the plunger to aspirate the solution into the syringe.

(4) Hold the tip of the syringe as close to the wound as possible without touching it.

(5) Depress the bulb (plunger) of the syringe, and direct the flow of solution to all parts of the wound.

(a) Pay particular attention to areas with debris, sweat, and/or drainage.

(b) Take extra care when irrigating a wound in which an abscess has formed. An abscess is simply a localized collection of pus. If the pressure within an abscess goes unrelieved, it may cause a sinus tract (an opening between the abscess and body surfaces).

(6) Repeat the procedure until the debris, sweat, and/or drainage has been flushed out of the wound.

(7) Remove the emesis (catch) basin from under the wound.

(8) Pat the wound dry with sterile gauze sponges.

n. Apply Sterile Dressing to Wound. Follow the procedures given in paragraph 4-7.

o. Perform Concluding Procedures.

(1) Remove the protective pad from under the wound.

(2) Remove the mask and gloves.

(3) Place the patient in a position of comfort that he likes.

(4) Dispose of contaminated items, especially soiled dressings, in accordance with local policy.

(5) Clean and store nondisposable items.

(6) Wash your hands.

(7) Report accomplishment of the procedure and observations to your supervisor and record any necessary information.

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Section I. Types of Isolation

5-1. CATEGORIES OF ISOLATION

Isolation is the separation of a patient from contact with others in order to control the spread of an infectious or communicable disease. Patients are isolated according to the mode of transmission of the disease.

a. Strict Isolation. Strict isolation is used to prevent the transmission of all highly communicable diseases that are spread by both, contact or airborne routes of transmission. Examples of such diseases are chickenpox and rabies.

b. Respiratory Isolation. Respiratory isolation is used to prevent transmission of organisms by means of droplets that are sneezed or breathed into the environment. Examples of such diseases are influenza and tuberculosis.

c. Protective Isolation. Protective isolation is used to prevent contact between potentially pathogenic microorganisms and uninfected persons who have seriously impaired resistance. Patients with certain diseases, such as leukemia, who are on certain therapeutic regimens are significantly more susceptible to infections.

d. Enteric Precautions. Enteric precautions are used to control diseases that can be transmitted through direct or indirect oral contact with infected feces or contaminated articles. Transmission of infection depends on ingestion of the pathogen. Examples of diseases requiring enteric precautions are dysentery and hepatitis.

e. Wound and Skin Precautions. Wound and skin precautions are used to prevent the spread of microorganisms found in infected wounds (including burns and open sores) and contact with wounds and heavily contaminated articles. Conditions requiring these precautions include infected burns, infected wounds, and infections with large amounts of purulent discharge. Diseases that may require wound and skin precautions include herpes, impetigo, and ringworm.

f. Blood Precautions. Blood precautions are used to prevent acquisition of infection by patients and personnel from contact with blood or items contaminated with blood. Examples of diseases that require blood precautions (refer to Lesson 1) are HBV and HIV/AIDS.

g. Discharge Precautions.

(1) Secretion precautions-lesions. These precautions are used to prevent acquisition of infection by personnel and patients from direct contact with wounds and secretion-contaminated articles. Some examples of diseases requiring these precautions are conjunctivitis, gonorrhea, and syphilis.

(2) Secretion precautions-oral. These precautions are used to prevent acquisition of infection by personnel from direct contact with oral secretions. Some examples of diseases requiring these precautions are herpes areolas and scarlet fever.

(3) Excretion precautions. These precautions are used to prevent acquisition of infection by personnel and patients from direct contact with fecal excretions. Some examples of diseases requiring these precautions are poliomyelitis and staphylococcal food poisoning.

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5-2. SIGNS USED TO IDENTIFY TYPES OF ISOLATION

Concise information on isolation in effect is put on signs placed on the door of the isolation room at eye level. Some hospital signs are disease specific, and other hospital signs are category specific. The sign is removed when isolation is no longer required. A checklist is also placed on the door. This list indicates whether masks, gowns, gloves, etc. are required for persons entering the room. Any other pertinent information is also on this sign.

a. Strict Isolation.

(1) Visitors must report to the nurses' station before entering the room.

(2) Door must be kept closed.

(3) Gowns must be worn by all persons entering the room.

(4) Masks must be worn by all persons entering the room.

(5) Hands must be washed on entering and leaving the room.

(6) Gloves must be worn by all persons entering the room.

(7) Articles must be discarded or wrapped before being sent to Central Supply for disinfection or sterilization.

b. Respiratory Isolation.

(1) Visitors must report to the nurses' station before entering the room.

(2) Door must be kept closed.

(3) Gowns are not necessary.

(4) Masks must be worn by any person entering the room unless that person is not susceptible to the disease.

(5) Hands must be washed on entering and leaving the room.

(6) Gloves are not necessary.

(7) Articles contaminated with secretions must be disinfected.

c. Protective Isolation.

(1) Visitors must report to the nurses' station before entering the room.

(2) Door must be kept closed.

(3) Gowns must be worn by all persons entering the room.

(4) Masks must be worn by all persons entering the room.

(5) Hands must be washed on entering and leaving the room.

(6) Gloves must be worn by all persons having direct contact with the patient.

(7) Articles must be handled according to local SOP.

d. Enteric Precautions.

(1) Visitors must report to the nurses' station before entering the room.

(2) Gowns must be worn by all persons having direct contact with the patient.

(3) Masks are not necessary.

(4) Gloves must be worn by all persons having direct contact with the patient or with articles contaminated with fecal material.

(5) Special precautions are necessary for articles contaminated with urine and feces. Articles must be disinfected or discarded.

e. Wound and Skin Precautions.

(1) Visitors must report to the nurses' station before entering the room.

(2) Gowns must be worn by all persons having direct contact with the infected wound.

(3) Masks are not necessary except during dressing changes.

(4) Gloves must be worn by all persons having direct contact with the infected area.

(5) Special precautions are necessary for instruments, dressings, and linens.

CAUTION: Only hospital personnel who have been vaccinated with poliomyelitis vaccine should have direct contact with patients who have active poliomyelitis.

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