Definition:

Sterilization : Processes by which all pathogenic & non

pathogenic microorganisms, including spores, are killed.

Disinfection: Chemical or physical process of destroying

all pathogenic microorganisms, except spore bearing
ones; used for inanimate objects, but not on tissues.
Definition:

Decontamination : Process or method by which all

contaminated materials that can cause diseases are
removed.

Aseptic techniques : Methods by which contamination with

microorganisms is prevented.
Antiseptic techniques: Prevention of sepsis by the exclusion,
destruction, or inhibition of growth and multiplication of
microorganisms from body tissues and fluids.
Historical backgrounds :

 Ignas Sammelweis (1818 - 1865)

Puerperal fever → increased maternal mortality
Hand scrub with chlorinated-lime solution prior to
examination.
Father of nosocomial infection.

 Louis Pasteur (1860)

Discover the process of fermentation by microorganisms
Germ theory: against spontaneous generation theory.
Historical backgrounds :

 Joseph Lister (1865)

Use carbolic acid solution on surgical dressing in the
operating room → mortality ↓ (Listerization)
Father of modern surgery (Antiseptic technique)

 Ernst Von Bergmann (1886)

Introduced “steam sterilizer”
Basic of sterilization → aseptic technique
Later: “pressure & vacuum steam sterilizer” was developed
Methods of Infection
control

 Anti septic techniques

 Design and traffic patterns of the

operating theatre
Sterilization

 The objective of modern surgery

 For inanimate objects
 Problem :
Some items are not heat resistance
Techniques of
Sterilization
 Physical:
Heat
Radiation/ ultraviolet ray
Boiling water
Ultrasound
 Chemical:
Liquid
Gas
Heat Sterilization

 Dry :
Commonly cause damage
For powder, oils, and jelly
 Moist :
Steam
High pressure ↑ → spores ↓
Vacuum → constant temperature
Autoclave
Chemical Sterilization

 Generally as disinfection
 Mechanism of action :
Protein coagulation
Enzyme denaturation in cells
Lysis

 Depend on : number of microorganisms, soiling,

concentration, and temperature.
Solutions

 Jodium and Jodophor

Good bactericide, but irritant
Mixture : povidone-jodine 10%
 Alcohol Solution of 70% or 90%

 Glutaraldehyde (Formaldehyde Sol. in Alcohol 2%)

Spores are killed within 3 hours
Solutions

 Hexachloropene (Halogenated phenol)

Bacterio-static, particularly Gram (+) bacteria
For scrubbing

 Chlorhexidine gluconate
Bactericide : Gram (+) & (-).
Good for antiseptic
Gas Sterilization

 Formaldehyde
 Ethilene-oxide
 β- propionolactone
Boiling Water

 Mild boiling
 Vigorous boiling

 More active, if 2% sodium-carbonate or 0,1 % sodium-

hydroxide being added
The Operating Theater

S
Clean C
Zone R
Transitional U
B Restricted area Sterile
Zone
Semi – core
S
Restricted
U
Area I
T
 Traffic patterns of Operating Theatre

 The use of aseptic principles requires

regulation of traffic and flow patterns of the
personnel, patient, equipment, and supplies
in operating theatre

 Aims : to protect the safety and privacy of

patients and the cleanliness and integrity of
the environment.
 unrestricted area

 A. OUTERZONE - Areas for

receiving patients
messengers, toilets,
administrative
function,Corridors outside
surgical suite
 unrestricted area

 Entrance

 Reception
desk

 Patient
suite
 Transitional Zone
(Video)

 Locker
room

 Dressing
room
 Clean Zone

 Changing room
 Patient transfer area
 Stores room
 Nursing staff room
 Anaesthetist room
 Recovery room
 ASEPTIC ZONE

•Scrub area

•Preparation room,

•Operation theatre,

•Area for instrument packing

and sterilization.
Sterile Core
DISPOSABLE ZONE
 Area where
used
equipment are
cleaned and
biohazardous
waste is
disposed
FORMALDEHYDE FUMIGATION
Commonly used to sterilize the OR.
For an area of 1000 cubic feet

REQUIREMENT
• 500 ml of 40% formaldehyde in one
litre of water
• Stove or hot plate for heating
Formalin
• 300 ml of 10% Ammonia
PROCEDURE
COMMERCIALLY AVAILABLE DISINFECTANT

•Bacillocid special
Is a surface and environmental disinfectant
• Has a very good cleansing property along with
bactericidal, virucidal , sporicidal and fungicidal
Activity

Composition
Each 100 g contains:
• 1.6 Dihydroxy 11.2G( Chemically bound
formaldehyde)
• Glutaraldehyde 5.0g
• Benzalkonium chloride 5.0g
• Alkyl urea derivatieves 3.0g
MOPPING OF FLOORS

3 bucket system

1st Bucket with water :

-dirty mop is rinsed

2nd Bucket with fresh water for rinsing ;

-Mop rinsed again in this water

3rd Bucket with low level disinfectant

-Mop is immersed in the solution and the floor
mopped liberally .
ULTRA VIOLET RADIATION

• Daily U.V. Irradiation for 12 -16 hrs

•To be switched off 2 hrs before Surgery

ULTRA SONIC CLEANER USED FOR

-Cleaning of micro surgical instruments and instruments with hinged areas and
serrated Edges

PRINCIPLE
Sound waves pass at a frequency of 100,000hz or more in the liquid.These
waves generate submicroscopic bubbles, which then collapse creating a
negative pressure on the particles in the suspension.
ARRANGEMENT OF INSTRUMENTS AND PACKING

•Arrange the instruments in trays

•Place heavy instruments at the bottom of the tray

•Place a signolac indicator inside the tray

•Double wrap the instruments set with linen

•Apply a signolac indicator with a dated label out side

the pack also.

STERILIZATION
Sterilization is a complete destruction of all microorganisms,
(both the vegetative forms and their spores.)

Sterilizing agents available

•Steam under pressure [AUTOCLAVE]
•Ethylene oxide [ E.T.O. ]
•High-level disinfectant
•Irradiation
AUTOCLAVE

Steam sterilization:
Autoclaving is suitable for sterilization of most metallic
ophthalmic instruments, except sharp knives and fine
scissors.

Autoclaving at 121°C for 20 minutes at 15 lbs psi

pressure effectively kills most microorganisms &
spores

Types of autoclaves

•Gravity displacement type

• Pre vacuum type.
• Vertical or horizontal type
AUTOCLAVE (VERTICAL
WORKING OF AN AUTOCLAVE

Various stages in the process of autoclaving

1. Loading 5. Holding
2. Closing 6. Exhaust
3. Air removal 7. Drying
4. Steam exposure 8. Unloading

Autoclaving at 121 degree C/ 15 lbs for 20 min

effectively kills micro organisms and their spores.

FLASH STERILISATION
Emergency sterilization
132º C at 30 lbs of pressure for 3mnts
ETHYLENE OXIDE (E.T.O.)

• Kills micro organisms by altering their DNA

by alkylation.

•Widely used for resterilising ‘ packaged heat sensitive

devices’ like sharp knives and blades.

• Effective and safe for heat labile tubings, vitrectomy

cutters, cryoprobes, light pipes, laser probes, diathermy
leads.
ETHYLENE OXIDE (E.T.O.)
A typical ETO sterilization cycle includes:

1. Packing of the articles to be sterilized.

2. Arranging and loading the sterilizer

3. Air removal with a vacuum pump

4. Heating to the required temperature, ( 45 C– 55 C )

5. Steam humidification maintained at a relative humidity

of 60 % E.T.O
 Exposure to the ETO at 5 psi for 12 hours or 10 psi for 6 hours
6. Gas removal by 70 psi vacuum.
7. Air flush by filtered air repeated 4 times to reestablish
atmospheric pressure
8. Aeration to elute residual ETO .
GLUTARALDEHYDE ( 2%)
•Suitable for Instruments that cannot be autoclaved .
•Sharp cutting instruments, plastic & rubber items , Endoscopes.
•Effective against Vegetative pathogens in 15 mts and resistant
pathogenic spores in 3 hrs.

Caution

should be thoroughly rinsed serially 2 to 3 times in trays filled with

sterile water.
GAMMA IRRADIATION
•Cold sterilization
•High penetrating power
•Lethal to DNA
•No appreciable rise in temperature
•Most useful for disposable & rubber items as well as ringer
lactate
MICROBIOLOGICAL MONITORING

Swabbing and culture for bacteria in OR

Frequency -Once a month
Areas swabbed – In all ORs
1. Operation table at the head end
2. Over head lamp
3. Four Walls.
4. Floor below the head end of the table
5. Instrument trolley
6. AC duct
7. Microscope
MICROBIOLOGICAL MONITORING

Quality of air in OR

Settle plate method

Frequency ( Once a month)

Procedure

One plate of blood agar and sabouraud

dextrose agar (SDA) is placed in the center
of the OR (Close to operation table) and the
lid is kept open for 30 min.
Bowie–Dick tapes(signolac)
This watermark does not appear
in the registered version -
http://www.clicktoconvert.com
Putting on surgical
attire

 In the semi & restricted area:

Scrub suit : shirt & trousers

Hair covering: surgical cap/hood
Masks : disposable/ re-useable
Goggle (optional): protective eyewear
Shoe covers

are compulsory
Surgical attire

 Male
personnel

 Female
personnel

 Personnel
with veil
Surgical Instruments in the Operating
Theatre

 Critical items :
Sterile, because of being used for penetrating skin or
mucosa

 Semi critical items :

In contact with skin or mucous membrane

 Non critical items :

PREOPERATIVE PREPARATION
PRINCIPLES OF STERILE TECHNIQUE
 The patient is the center of the sterile field. It
includes the areas of the patient, the operating
table and furniture covered with sterile drapes,
and the personnel wearing the OR attire.
 Strict adherence to sound principles of sterile
technique and recommended practices is
mandatory for the safety of the patient. This
adherence reflects one’s surgical concience.
 If the principles are understood, the need for
their application becomes obvious. The sterile
technique is the basis of modern surgery.
1. ONLY STERILE ITEMS ARE USED WITHIN THE
STERILE FIELD.
 If you are in doubt about the sterility of anything
consider it not sterile.
 Known or potentially contaminated items must not
be transferred to the field.
a. If sterile package is found in a nonsterile
workroom.
b. If uncertain about actual timing or operation of
sterilizer.
c. If unsterile person comes into close contact
with a sterile table and vice versa.
d. If sterile table or unwrapped sterile items are
not under constant observation.
e. If sterile package falls to the floor; it must
then be discarded.
2. GOWNS ARE CONSIDERED STERILE ONLY FROM THE
WAIST TO THE SHOULDER LEVEL, IN FRONT AND THE
SLEEVES.
 When wearing a gown, consider only the are you can see
down the waist as the sterile area. The following
practices must be observed:
a. Sterile persons keep hands in sight or above waist
level.
b. Hands are kept away from the face. Elbows are
kept close to sides. Hands are never folded under
arms.
c. If a sterile person must stand on a platform to
reach the operative field, the area of the gown
below waist must not brush against sterile tables or
draped areas.
d. Items dropped below the waist level are considered
unsterile and must be discarded.
3. TABLES ARE STERILE ONLE AT TABLE LEVEL.
a. Only top of a table with sterile drape is
considered sterile. Edges and sides of drape
extending below the table level are considered
unsterile.
b. Anything falling or extending over table edge,
such as a piece suture, is unsterile. Scrub
nurse does not touch the part hanging below
that level.
c. In unfolding sterile drape, the part that drops
below table surface is not brought back up to
the table level.
4. PERSONS WHO ARE STERILE TOUCH ONLY
STERILE ITEMS OR AREAS; PERSON WHO ARE
NOT STERILE TOUCH ONLY UNSTERILE ITEMS OR
AREAS.
a. Sterile team members maintain contact with
sterile field by means of gowns and gloves.
b. Nonsterile, circulating nurse does not directly
come into contact with the sterile field.
c. Supplies for sterile team members reach them by
means of the circulating nurse who opens
wrapper on sterile package.
5. UNSTERILE PERSONS AVOID REACHING OVER A
STERILE FIELD; STERILE PERSONS AVOID
LEANING OVER AN UNSTERILE AREA.
a. Unsterile circulating nurse never reach over a
sterile field to transfer sterile items.
b. In pouring solution into sterile basin, circulating
nurse holds only lip of bottle over basin to avoid
reaching over a sterile area.
c. Scrub nurse sets basins or glasses to be filled at
edge of the sterile table.
d. Circulating nurse stands at a distance from the
sterile field.
e. Surgeon turns away from sterile field to have
perspiration removed from brow.
6. EDGES OF ANYTHING THAT ENCLOSES STERILE
CONTENTS ARE CONSIDERED UNSTERILE.
a. In opening sterile package, ends of flaps are
secured in hand so they do not dangle loosely.
b. Flaps on the peel open packages should be pulled
back, not torn to expose sterile contents.
Contents should be lifted upward or flipped.
c. After bottle is opened contents must be used or
discarded.
d. If a sterile wropper is used as a table cover, it
should cover aply the entire table surface. Only
the interior and surface level of the cover are
considered sterile.
7. STERILE FIELDS ARE CREATED AS CLOSE AS
POSSIBLE TO TIME OF USE.
 Degree of contamination is proportionate to length
of time sterile items are uncovered and exposed to
the environment. Precautions must be taken as
follows:
a. Sterile tables are set up justprior to the opertation.
b. If is difficult to uncover a table. Therefore it is not
recommended for later use.
8. STERILE AREAS ARE CONTINUOUSLY KEPT
IN VIEW.
 Inadvertent contamination of sterile areas
must be readily visible. To ensure this
principle:
a. Sterile persons face sterile areas.
b. When sterile packs are opened in a room,
or a sterile field is set up, someone must
remain in the room to maintain vigilance.
9. STERILE PERSONS KEEP WELL WITHIN THE
STERILE AREA.
 Allow a wide margin of safety when passing
unsterile areas and follow these rules:
a. Sterile persons stand back at a safe distance from
the OR table when draping the patient.
b. Sterile persons pass each other back to back
c. Sterile persons turns back to nonsterile person or
area when passing.
d. Sterile persons face sterile are to pass it.
e. Sterile persons asks nonsterile individual to step
aside rather than risk contamination.
f. Sterile persons stay within and around a sterile
field.
g. Movement within and around a sterile area is kept
to a minimum to avoid contamination of sterile
items or persons.
10. STERILE PERSONS KEEP CONTACE WITH STERILE
AREAS TO A MINIMUM
 Sterile persons do not lean on sterile tables and on the
draped patient.
 Sitting or leaning against a nonsterile surface is a break
in technique.
11. UNSTERILE PERSONS AVOID STERILE AREAS.
 A wide margin of safety must be maintained when
passing sterile areas by ff. these rules:
a. Unsterile person maintains at least 1foot (30cm)
distance from any sterile area.
b. Unsterile persons face & observe a sterile area when
passing to be sure they do not touch it.
c. Unsterile persons never walk between two sterile areas.
d. Circulating nurse restricts to a minimum all activities
near sterile field.
12. DESTRUCTION OF INTEGRITY OF MICROBIAL
BARRIERS RESULT IN CONTAMINATION.
 Integrity of a sterile package of sterile drape is
destroyed by perforation, puncture or strike-
through. Strike through is soaking of moisture
through unsterile layers to sterile layers or vice
versa.
 Ideal barrier materials sre abrasion resistant,
impervious to permeation of fluids or dust that
transport microorganisms.
 The integrity of a sterile package, its expiration
date and appearance of process monitor must be
checked for sterility just prior to opening.
 To ensure sterility:
a. Sterile packages are laid on dry surfaces.
b. If sterile package becomes damped or
wet, it is re-sterilized or discarded.
c. Drapes are placed on a dry field.
d. If solution soaks through sterile drape to
nonsterile area, the wet area is covered
with impervious sterile drape or towels.
e. Sterile items are stored with clean dry
hands.
f. Undue pressure on sterile packs is
avoided to prevent forcing sterile air out
and pulling unsterile air into the pack.
13. MICROORGANISMS MUST BE KEPT TO AN
IRREDUCABLE MINIMUM.
 Perfect asepsis in an operative field is an ideal to
be approached; it is not absolute. All
microorganisms cannot be eliminated, but this
does not obviate necessity for strict sterile
technique. It is generally agreed that:
a. Skin cannot be sterilized
b. Some areas cannot be scrubbed
c. Infected areas are grossly contaminated
d. Air is contaminated by dust and droplets
THE OPERATING ROOM ATTIRE
 Consists of the scrub dress, head cover, mask and
shoes or shoe cover. Sterile gown and gloves are
added for srubbed team.
 Provides effective barriers that prevent the
dissemination of microorganisms to the patients
and to protect personnel from infected patients.
1. Scrub dress – worn only in the operating suite.
2. Head cover – is used to cover hair completely.
3. Shoes – should be clean and conductive washable
and soft soled covered by shoe covers.
4. Mask – is put on by all personnel before coming
into the OR and must be worn over nose and
mouth.
5. Sterile gown – are worn over scrub attire.
6. Sterile gloves – are worn to complete the attire for
srcubbed members.
POSITIONS FOR SURGERY
 Surgical positioning is the practice of placing
a patient in a particular physical position
during surgery. The goal in selecting and adjusting a
particular surgical position is to maintain the
patient's safety while allowing access to the surgical
site. Often a patient must be placed in an unnatural
position to gain access to the surgical site.
 The selection of a surgical position is made after
considering relevant physical and physiological
factors, such as body alignment, circulation,
respiratory constraints, and the musculatory system
to prevent stress on the patient. Physical traits of the
patient must also be considered including size, age,
weight, physical condition, and allergies.
 The type of anesthesia used also affects the decision.
Changing Positions
 If the patient has been immobilized, it may be
important to change the patient's position
periodically to prevent blood pooling, to
stimulate circulation, and to relieve pressure
on tissues.
 The patient should not be placed in unnatural
positions for an extended period of time. After
anesthesia, the patient's inability to react to
movements may damage joints and muscle
groups. Considerations should be taken not to
damage these muscle groups by, for example,
moving both legs simultaneously.
Risk for Extremities
 The most common nerve injuries during
surgery occur in the upper and lower
extremities. Injuries to the nerves in the arm
or shoulder can result in numbness, tingling,
and decreased sensory or muscular use of the
arm, wrist, or hand. Many operating room
injuries could be solved by simply restraining
the arms and legs. Other causes of nerve or
muscular damage to the extremities is caused
by pressure on the body by the surgical team
leaning on the patient's arms and legs. The
patient's arms can be protected from these
risks by using an arm sled.
Positions
Supine position - The most common surgical position.
The patient lies with back flat on operating room
bed.
Trendelenburg position - Same as supine position but
the upper torso is lowered.
Reverse Trendelenburg position - Same as supine but
upper torso is raised and legs are lowered.
Fracture Table Position - For hip fracture surgery.
Upper torso is in supine position with unaffected leg
raised. Affected leg is extended with no lower
support. The leg is strapped at the ankle and there
is padding in the groin to keep pressure on the leg
and hip.
Lithotomy position - Used for gynecological, anal, and
urological procedures. Upper torso is placed in the
supine position, legs are raised and secured, arms
Fowler's position - Begins with patient in supine
position. Upper torso is slowly raised to a 90
degree position.
Semi-Fowlers position - Lower torso is in supine
position and the upper torso is bent at a nearly 85
degree position. The patient's head is secured by a
restraint.
Prone position - Patient lies with stomach on the bed.
Abdomen can be raised off the bed.
Jackknife position - Also called the Kraske position.
Patient's abdomen lies flat on the bed. The bed is
scissored so the hip is lifted and the legs and head
are low.
Knee-chest position - Similar to the jackknife except
the legs are bent at the knee at a 90 degree angle.
Lateral position - Also called the side-lying
position, it is like the jackknife except the
patient is on his or her side. Other similar
positions are Lateral chest and Lateral kidney.
Kidney position - The kidney position is much
like the lateral position except the patient's
abdomen is placed over a lift in the operating
table that bends the body to allow access to
the retroperitoneal space. A kidney rest is
placed under the patient at the location of the
lift.
Sims' position - The Sims' position is a variation
of the left lateral position. The patient is
usually awake and helps with the positioning.
The patient will roll to his or her left side.
Keeping the left leg straight, the patient will
slide the left hip back and bend the right leg.
This position allows access to the anus.
Setting Up An Unsterile Table As A
Sterile Field
 The scrub person
drapes an unsterile
table toward self
first to protect the
gown. Gloved hands
are protected by
cuffing a drape over
them.
 The scrub person
stands back from the
unsterile table when
draping it in order
avoid leaning over
an unsterile are.
 There Is No
Compromise with
Sterility
It’s Considered Sterile
or Unsterile.
The OR Scrub
 The Surgical Scrub

 Definition.
The surgical scrub is the process of
removing as many microorganisms as
possible from the hands and arms by
mechanical washing and chemical antisepsis
before participating in a surgical procedure.
 Despite the mechanical action and the
chemical antimicrobial component of the
scrub process, skin is never sterile.
The Methodology of the
Scrub
 The Timed Method

 All surgical scrubs are 5 minutes in

length.
All are performed using a surgical
scrub brush and an antimicrobial soap
solution.
Surgical Scrub Procedure
1. Wet the hands and
forearms
2. Apply antiseptic agent
from the dispenser to
the hands.
3. Wash the hands and
arms thoroughly to 2
inches above the
elbows, several times.
Rinse thoroughly under
running water with the
hands upward,
allowing water to drip
from the flexed elbows.
4. Take a sterile brush or
sponge (from a
package or dispenser)
and apply an antiseptic
agent ( if it is not
impregnated in the
brush). Scrub each
individual finger,
including the nails, and
the hands, a half
minute for each hand.
5. Hold the brush in one
hand and both hands
under running water,
and clean under the
fingernails with a
disposable plastic nail
cleaner. Discard the
cleaner after use.
6. Again scrub each
individual finger,
including the nails and
the hands with the
brush, half a minute
for each hand.
The Final Rinse
1. Be sure to keep both
arms in the upright
position (careful not to
touch the faucet!) so
that all water flows off
the elbows and not
back down to the
freshly scrubbed hands.
Bring arm through the
water once, starting
with the fingers, then
pull the arm straight
out. Do not let water
run down to hands,
must drip off elbows
7. Rinse the hands and brush, and
discard the brush.
8. Reapply the antimicrobial agent and
wash the hands and arms, applying
friction to the elbows, for 3 minutes.
Interlace the fingers to clean between
them.
9. Rinse the hands and arms as
described in the previous slide.
Drying the Hands and
Arms
1. Reach down to the
opened sterile package
containing the gown,
and pick up the towel.
Be careful not to drip
water onto the pack.
Be sure no one is
within arm’s reach.
2. Open the towel full-
length, holding one
end away from the
nonsterile scrub attire.
Bend slightly forward.
3. Dry both hands
thoroughly but
independently. To dry
one arm, hold the
towel in the opposite
hand and, using the
oscillating motion of
the arm, draw the
towel up to the elbow.
4. Carefully reverse the
towel, still holding it
away from the body.
Dry the opposite arm
on the unused end of
the towel.
Gowning and Gloving
Techniques
1. Reach down to the
sterile package and lift
the folded gown
directly upward.
2. Step back away from
the table into an
unobstructed area to
provide a wide margin
of safety while
gowning.
3. Holding the folded
gown, carefully locate
the neckline.
4. Holding the inside
front of the gown just
below the neckline with
both hands, let the
gown unfold, keeping
the inside of the gown
toward the body. Do
not touch the
outside of the gown
with bare hands.
5. Holding the hands at
shoulder level, slip
both arms into the
armholes
simultaneously.
6. The circulator brings
the gown over the
shoulders by reaching
inside to the shoulder
and arm seams. The
gown is pulled on,
leaving the cuffs of
the sleeves
extended over the
hands. The back of
the gown is securely
tied or fastened at the
neck and waist, touch
the outside of the
gown at the line of ties
or fasteners in the
back only.
Gloving by the Closed
Glove Technique
1. Using the right hand and keeping it
within the cuff of the sleeve, pick
up the left glove from the inner
wrap of the glove package by
grasping the folded cuff.
2. Extend the left forearm
with the palm upward.
Place the palm of the
glove against the palm
of the left hand,
grasping in the left
hand the top edge of
the cuff, above the
palm. In correct
position, glove fingers
are pointing toward
you and the thumb of
the glove is down
3. Grasp the back of
the cuff in the left
hand and turn it
over the end of the
left sleeve and
hand. The cuff of
the glove is now
over the
stockinette cuff of
the gown, with the
hand still inside the
sleeve.
4. Grasp the top of
the left glove
and underlying
gown sleeve
with the covered
right hand. Pull
the glove on
over the
extended right
fingers until it
completely
covers the
5. Glove the right
hand in the
same manner,
reversing hands.
Use the gloved
left hand to pull
on the right
glove.
Gloving the Right Hand
Scrubbing, Gowning, and Gloving
Complete