PERIOPERATIVE NURSING BASICS

STERILE TECHNIQUE
An object is sterile only when it is free of all microorganisms. It is well known that sterile technique is practiced in
operating rooms and special diagnostic areas. Less known perhaps is that sterile technique is also employed for many
procedures in general care areas (such as administering injections, changing wound dressings, performing urinary
catheterizations, and administering intravenous therapy)

PRINCIPLES AND PRACTICES OF SURGICAL ASEPSIS

PRINCIPLES PRACTICES
All objects used in All articles are sterilized appropriately by dry or moist heat, chemicals, or radiation before use.
a sterile field must Always check a package containing a sterile object for intactness, dryness, and expiration date.
be sterile. Sterile articles can be stored for only a prescribed time; after that, they are considered
unsterile. Any package that appears already open, torn, punctured, or wet is considered
unsterile. Storage areas should be clean, dry, off the floor, and away from sinks. Always check
chemical indicators of sterilization before using a package. The indicator is often a tape used to
fasten the package or contained inside the package. The indicator changes color during
sterilization, indicating that the contents have undergone a sterilization procedure. If the color
change is not evident, the package is considered unsterile. Commercially prepared sterile
packages may not have indicators but are marked with the word. Sterile.
Sterile objects Handle sterile objects that will touch open wounds or enter body cavities only with sterile
become unsterile forceps or sterile gloved hands. Discard or re-sterilize objects that come into contact with
when touched by unsterile objects. Whenever the sterility of an object is questionable, assume the article is
unsterile objects. unsterile.
Sterile items that Once left unattended, a sterile field is considered unsterile. Sterile objects are always kept in
are out of vision or view. Nurses do not turn their backs on a sterile field. Only the front part of a sterile gown, from
below the waist or shoulder to waist (or table height, whichever is higher), and the cuff of the sleeves to 2 inches
table level are above the elbows are considered sterile. Always keep sterile gloved hands in sight and above
considered waist/table level; touch only objects that are sterile. Sterile draped tables in the operating room
unsterile. or elsewhere are considered sterile only at surface level.
Sterile objects can Keep doors closed and traffic to a minimum in areas where a sterile procedure is being
become unsterile performed, because moving air can carry dust and microorganisms. Keep areas in which sterile
by prolonged procedures are carried out as clean as possible by frequent damp cleaning with detergent
exposure to germicides to minimize contaminants in the area. Keep hair clean and short or enclose it in a
airborne net to prevent hair from falling on sterile objects. Microorganisms on the hair can make a sterile
microorganisms. field unsterile. Wear surgical caps in operating rooms, delivery rooms, and burn units. Refrain
from sneezing or coughing over a sterile field. This can make it unsterile because droplets
containing microorganisms from the respiratory tract can travel 1 m (3 ft). Some agencies
recommend that masks covering the mouth and the nose should be worn by anyone forking
over a sterile field or an open wound. Nurses with mild upper respiratory tract infections refrain
from carrying out sterile procedures or wear masks. When working over a sterile field, keep
talking to a minimum. Avert the head from the field if talking is necessary. To prevent
microorganisms from falling over a sterile field, refrain from reaching over a sterile field unless
sterile gloves are worn and refrain from moving unsterile objects over a sterile field.
Fluids flow in the Unless gloves are worn, always hold wet forceps with the tips below the handles. When the tips
direction of gravity are held higher than the handles, fluid can flow onto the handle and become contaminated by
the hands. When the forceps are again pointed downward, the contaminated fluid flows back
down and contaminates the tips. During a surgical hand wash, hold the hands higher than the
elbows to prevent contaminants from the forearms from reaching the hands.
Moisture that Sterile moisture-proof barriers are used beneath sterile objects. Liquids (sterile saline or
passes through a antiseptics) are frequently-poured into containers on a sterile field. If they are spilled onto the
sterile object draws sterile field, the barrier keeps the liquid from seeping beneath it. Keep the sterile covers on
microorganisms sterile equipment dry. Damp surfaces can attract microorganisms in the air. Replace sterile
from unsterile drapes that do not have a sterile barrier underneath when they become moist. A 2.5-cm (1-in.)
surfaces above or margin at each edge of an opened drape is considered unsterile because the edges are in
below to the sterile contact with unsterile surfaces. Place all sterile objects more than 2.5 cm (1 in.) inside the edges
surface by capillary of a sterile field. Any article that falls outside the edges of a sterile field is considered unsterile.
action. The edges
of a sterile field are
considered
unsterile.
The skin cannot be Use sterile gloves or sterile forceps to handle sterile items. Prior to a surgical aseptic procedure,
sterilized and is cleanse the hands to reduce the number of microorganisms on them.
unsterile.
Conscientiousness, When a sterile object becomes unsterile, it does not necessarily change in appearance. The
alertness, and person who sees a sterile object become contaminated must correct or report the situation. Do
honesty are not set up a sterile field ahead of time for future use.
essential qualities
in maintaining
surgical asepsis.

STERILE FIELD
A sterile field is a microorganism-free area. Nurses often establish a sterile field by using the innermost side of a sterile
wrapper or by using a sterile drape. When the field is established, sterile supplies and sterile solutions can be placed on
it. Sterile forceps are used in many instances to handle and transfer sterile supplies.

So that sterility can be maintained, supplies may be wrapped in a variety of materials. Commercially prepared items are
frequently wrapped in plastic, paper, or glass. In the past, it was not unusual for sterile liquids (e.g., sterile water for
irrigations) to be supplied in large containers and used many times. This practice is considered undesirable today
because once a container has been opened, there can be no assurance that it will remain sterile. Liquids are preferably
packaged in amounts adequate for one use only. Any leftover liquid is discarded.

ESTABLISHING AND MAINTAINING A STERILE FIELD

Purpose
To ensure that sterile items remain sterile

Equipment
Package containing a sterile drape
Sterile equipment as needed (e.g., wrapped sterile gauze, wrapped sterile bowl, antiseptic solution, sterile forceps)

IMPLEMENTATION

Preparation
 Ensure that the package is clean and dry; if moisture is noted on the inside of a plastic-wrapped package or the
outside of a cloth wrapped package, it is considered contaminated and must be discarded.
 Check the sterilization expiration dates on the package, and look for any indications that it has been previously
opened. Spots or stains on cloth or paper-wrapped objects may indicate contamination, and the objects should
not be used. as
 Follow agency practice for disposal of possibly contaminated packages.
Performance
1. Prior to performing the procedure, introduce self and verify the clients’ identity using agency protocol. Explain
to the client what you are going to do, why it is necessary, and how he or she can cooperate. Discuss how the
results will be used in planning further care or treatments.
2. Observe other appropriate infection control procedures.
3. Provide for client privacy.
4. Open the package. If the package is inside a plastic cover, remove the cover.
 To Open a Wrapped Package on a Surface
o Place the package in the work area so that the top flap of the wrapper opens away from you.
o Reaching around the package (not over it), pinch the first flap on the outside of the wrapper between
the thumb and index finger.
 Rationale: Touching only the outside of the wrapper maintains the sterility of the inside of the
wrapper. Pull the flap open, laying it flat on the far surface.
o Repeat for the side flaps, opening the top one first. Use the right hand for the right flap, and the left
hand for the left flap.
 Rationale: By using both hands, you avoid reaching over the sterile contents
o Pull the fourth flap toward you by grasping the corner that is turned down. Make sure that the flap does
not touch any object.
 Rationale: If the inner surface touches any unsterile article, it is contaminated
 Variation: Opening a Wrapped Package While Holding It
o Hold the package in one hand with the top flap opening away from you.
o Using the other hand, open the package as described above, pulling the corners of the flaps well back. O
Tuck each of the corners into the hand holding the package so that they do not flutter and contaminate
sterile objects.
 Rationale: The hands are considered contaminated, and at no time should they touch the
contents of the package.
 Variation: Opening Commercially Prepared Packages
o If the flap of the package has an unsealed corner, hold the container in one hand, and pull back on the
flap with the other hand.
o If the package has a partially sealed edge, grasp both sides of the edge, one with each hand, and pull
apart gently.
5. Establish a sterile field by using a drape.
o Open the package containing the drape as described above.
o With one hand, pluck the corner of the drape that is folded back on the top touching only one side of
the drape.
o Lift the drape out of the cover, and allow it to open freely without touching any articles.
 Rationale: If the drape touches the outside of the package or any unsterile surface, it is
considered contaminated.
o With the other hand, carefully pick up another corner of the drape, holding it well away from you, and
again, touching only the same side of the drape as the first hand.
o Lay the drape on a clean and dry surface, placing the bottom (i.e., the freely hanging side) farthest from
you.
 Rationale: By placing the lowermost side farthest away, you avoid leaning over the sterile field
and contaminating it
6. Add necessary sterile supplies, being careful not to touch the drape with the hands.
 To Add Wrapped Supplies to a Sterile Field
o Open each wrapped package as described in the preceding steps.
o With the free hand, grasp the corners of the wrapper, and hold them against the wrist of the other hand.
 Rationale: The sterile wrapper now covers the unsterile hand.
o Place the sterile bowl, drape, or other supply on the sterile field by approaching from an angle rather
than holding the arm over the field.
o Discard the wrapper.
 Variation: Adding Commercially Packaged Supplies to a Sterile Field
o Open each package as previously described.
o Hold the package 15 cm (6 in.) above the field, and allow the contents to drop on the field. Keep in mind
that 2.5 cm (1 in.) around the edge of the field is considered contaminated.
 Rationale: At a height of 15 cm (6 in.), the outside of the package is not likely to touch and
contaminate the sterile field.
 Adding Solution to a Sterile Bowl
7. Liquids (e.g., normal saline) may need to be poured into containers within a sterile field. Unwrapped bottles that
contain sterile solution are considered sterile on the inside and contaminated on the outside because the bottle
may have been handled. Bottles used in an operating room may be sterilized on the outside as well as the inside,
however, and these are handled with sterile gloves.
o Before pouring any liquid, read the label three times to make sure you have the correct solution and
concentration (strength). Wipe the outside of the bottle with a damp towel to remove any large
particles that could fall into the bowl or field.
o Obtain the exact amount of solution, if possible.
 Rationale: Once a sterile bottle has been opened, its sterility cannot be ensured for future use.
Follow agency policy for reuse of opened sterile solution bottles.
o Remove the lid or cap from the bottle and invert the lid before placing it on a surface that is not sterile.
 Rationale: Inverting the lid maintains the sterility of the inside surface because it is not allowed
to touch an unsterile surface.
o Hold the bottle at a slight angle so that the label is uppermost.
 Rationale: Any solution that flows down the outside of the bottle during pouring will not
damage or obliterate the label.
o Hold the bottle of fluid at a height of 10 to 15 cm (4 to 6 in.) over the bowl and to the side of the sterile
field so that as little of the bottle as possible is over the field.
 Rationale: At this height, there is less likelihood of contaminating the sterile field by touching
the field or by reaching an arm over it
o Pour the solution gently to avoid splashing the liquid.
 Rationale: If a barrier drape (one that has a water-resistant layer) is not used and the drape is on
an unsterile surface, moisture will contaminate the field by wicking microorganisms through the
drape.
o Tilt the neck of the bottle back to vertical quickly when done pouring so that none of the liquid flows
down the outside of the bottle.
 Rationale: Such drips would contaminate the sterile field if the outside of the bottle is not
sterile.
o If the bottle will be used again, replace the lid securely and write on the label the date and time of
opening.
 Rationale: Replacing the lid immediately maintains the sterility of the inner aspect of the lid and
the solution.
o Depending on agency policy, a sterile container of solution that is opened may be used only once and is
then discarded (such as in the operating room). In other settings, policy may permit recapped bottles to
be reused within 24 hours.
8. Use sterile forceps to handle sterile supplies. Forceps are usually used to move a sterile article from one place to
another, for example, transferring sterile gauze from its package to a sterile dressing tray. Forceps may be
disposable or re-sterilized after use. Commonly used forceps include hemostats and tissue forceps.
o If forceps tips are wet, keep the tips lower than the wrist at all times, unless you are wearing sterile
gloves.
 Rationale: Gravity prevents liquids on the tips of the forceps from flowing to the unsterile
handles and later back to the tips.
o Hold sterile forceps above waist or table level, whichever is higher.
 Rationale: Items held below waist or table level are considered contaminated.
o Hold sterile forceps within sight.
  Rationale: While out of sight, forceps may, unknown to the user, become unsterile. Any forceps
that go out of sight should be considered unsterile.
o When using forceps to lift sterile supplies, be sure that the forceps do not touch the edges or outside of
the wrapper.
 Rationale: The edges and outside of the sterile field are considered unsterile.
o When placing forceps whose handles were in contact with the bare hand, position the handles outside
the sterile area.
 Rationale: The handles of these forceps harbor microorganisms from the bare hand.
o Deposit a sterile item on a sterile field without permitting moist forceps to touch the sterile field when
the surface under the absorbent sterile field is unsterile and a barrier drape is not used.
9. Document that sterile technique was used in the performance of the procedure.

HANDWASHING

PURPOSES
 To reduce the number of microorganisms on the hands
 To reduce the risk of transmission of microorganisms to clients
 To reduce the risk of cross-contamination among clients
 To reduce the risk of transmission of infectious organisms to oneself

EQUIPMENT
• Hand wash basin
• Liquid soap
• Paper towels
• Domestic waste bin

Pre-procedure

Action Rationale
1 Remove any rings, bracelets and wristwatch still
worn and roll up sleeves. ( Note : It is good
practice to remove all hand and wrist jewelry and
roll up sleeves before entering any clinical area
and the English Department of Health has
instructed NHS trusts to implement a ‘bare below
the elbows’ dress code.)
2 Cover cuts and abrasions on hands with
waterproof dressing.

3 Remove nail varnish and artificial nails (most

uniform policies and dress codes prohibit these).
Nails must also be short and clean

Procedure

Action Rationale
4 Turn on the taps and where possible direct the
water flow away from the plughole. Run the
water at a flow rate that prevents splashing.
5 Run the water until hand hot.

6 Wet the surface of hands and wrists.

7 Apply liquid soap and water to all surfaces of

the hands.

8 Rub hands together for a minimum of 10–15

seconds, paying particular attention to between
the fingers and the tips of fingers and thumbs.
The areas that are most frequently missed
through poor hand hygiene technique are shown
in Action figure 8b.
9 Rinse soap thoroughly off hands.

10 Turn off the taps using your wrist or elbow. If

the taps are not lever-type, turn them off using a
paper hand towel to prevent contact.

Post-procedure

Action Rationale
11 Dry hands thoroughly with a disposable paper
towel from a towel dispenser.

12 Dispose of used paper towels in a black bag in

a foot-operated waste bin.

Action
1. Rub hands palm to palm.
2. Rub back of each hand with palm of other hand with fingers interlaced.
3. Rub palm to palm with fingers interlaced. Rub with back of fingers to opposing palms with fingers interlocked. Rub
tips of fingers. Rub tips of fingers in opposite palm in a circular motion.
4. Rub each thumb clasped in opposite hand using a rotational movement.
5. Rub each wrist with opposite hand.
6. Rinse hands with water.
 SURGICAL SCRUB TECHNIQUE

Purpose
To reduce the release of bacteria from the hands while carrying out surgical or high-risk procedures. The difference from
conventional hand washing is the reduction in the level of resident bacteria on the hands as well as removal of the
majority of transient bacteria.

Essential equipment
• Hand wash basin or surgical scrub sink with sufficient space available under the outlet to allow easy rinsing of hands
and forearms
• Liquid medicated soap
• Sterile towels
• Domestic waste bin

Optional equipment
Sterile scrubbing brush, nail file or other implement for cleaning beneath the nails.
Note that WHO (2009a ) guidelines recommend that scrubbing brushes should not be used as they may damage the skin
and encourage the shedding of cells (including bacteria).

Pre-procedure

Action Rationale
1 Remove any rings, bracelets and wristwatch still
worn and roll up sleeves before entering the
operating theatre or procedure area. (Note: Most
organizations will require staff entering operating
theatres to change into ‘scrubs’.)
2 Cover cuts and abrasions on hands with
waterproof dressing.

3 Remove nail varnish and artificial nails (most

uniform policies and dress codes prohibit these).
Nails must also be short and clean

Procedure

Action Rationale
4 Turn on the taps and where possible direct the
water flow away from the plughole. Run the
water at a flow rate that prevents splashing.

5 Run the water until hand hot.

6 Wet the surface of hands, wrists and forearms.

7 Apply medicated liquid soap and water to all

surfaces of the hands.

8 Clean beneath the nails using a sterile

implement (preferred) or soft scrubbing brush.

9 Start timing. Thoroughly wash the hands for 2

minutes, using the actions shown in Procedure
guideline 3.1: Hand washing,

10 Wash each arm from wrist to elbow for 1

minute, keeping the hand higher than the elbow
at all times.

11 Rinse hands and arms thoroughly from fi

ngertips to elbow, keeping the hands above the
elbows at all times

Post-Procedure

Action Rationale
12 Dry hands thoroughly with a sterile paper or
cloth towel. Dry in one direction only, from the
fingertips to the elbow.

13 Dispose of used paper towels in a black bag in

an open or foot-operated waste bin.
 DONNING A STERILE GOWN AND GLOVES: CLOSED TECHNIQUE

Note 1: These procedures will normally require participants to also wear a mask and eye protection.
Note 2: An assistant is required to open sterile gloves and tie the back of the gown.

Purposes
 To enable the nurse to work close to a sterile field and handle sterile objects freely
 To protect clients from becoming contaminated with microorganisms on the nurse's hands, arms, and clothing

Essential equipment
• Sterile disposable gloves
• Sterile disposable or reusable gown

Pre-procedure

Action Rationale
1 Prepare the area where gowning and gloving will take place. Open the gown
pack with clean hands. Do not touch the inside of the package.

2 Wash your hands using a surgical scrub technique with either antiseptic
hand wash solution or soap. Dry using a separate sterile paper towel for each
hand and forearm. If hands have been washed with soap, apply an antiseptic
hand rub to the hands and forearms.

Procedure

Action Rationale
3 Open the inner layer of the gown pack, if present

4 Grasp the gown on its inside surface just below the neck opening (this
should be uppermost if the gown pack has been opened correctly) and lift it
up, holding it away from the body and any walls or furniture. The gown should
fall open with the inside facing towards you
5 Insert the free hand into the corresponding sleeve of the gown, pulling the
gown towards you, until your fingers reach, but do not go beyond, the cuff of
the sleeve

6 Release the inside surface of the gown and insert that hand into the
corresponding sleeve, again until your fingers reach, but do not go beyond,
the cuff of the sleeve. The assistant should help to pull the gown on and tie
the ties, without touching any part of the gown other than the ties and rear
edges.
7 The assistant opens a pair of sterile gloves and presents the inner packaging
for you to take. Place this on the sterile area of the open gown package so
that the fingers of the gloves point towards you
8 Open the inner packaging of the gloves. The fingers should be towards you,
the thumbs uppermost and the cuff s folded over. Keeping your hands within
the sleeves of the gown, slide the thumb of your right hand (still inside the
sleeve) between the folded-over cuff and the body of the right glove. Pick up
that glove. Grasp the cuff of that glove on the opposite side with the other
hand (still inside its sleeve) and unfold it, pulling it over the cuff of the sleeve
and the hand inside. Then push your right hand through the cuff of the sleeve
into the glove. Repeat the process with the left hand. Once both hands are
inside their respective gloves, there is no risk of contaminating the outside of
the gloves or gown with your bare hands
9 If you need to change a glove because it is damaged or contaminated, pull
the sleeve cuff down over your hand as you do so and don the replacement
glove using the technique above.

10 Dispose of used gloves and disposable gowns as ‘hazardous infectious

waste’, that is, into an orange waste bag, unless instructed otherwise by the
infection prevention and control team.

Post-procedure

Action Rationale
11 At the end of the procedure, remove gown and gloves as a single unit by
pulling the gown away from you so as to turn it and the gloves inside out

12 Consign reusable gowns as infected linen according to local arrangements.

13 After removing the gloves and gown, decontaminate your hands.