USING PREPACKAGED STERILE KIT

ALERT
• To minimize contamination of your work area, gain the patient’s full cooperation by
explaining the procedure and advising him or her to avoid sudden movements, refrain
from touching supplies, and talk as little as possible (to avoid air droplet contamination).
• Assess the patient's comfort, oxygen requirements, and elimination needs before
preparing for the procedure.
• If a body part is to be examined or treated, position the patient so that the area is
accessible. Have NAP assist you with positioning the patient as needed.
• Remain organized and prepare the sterile field as close as possible to the time of use, to
reduce the potential for contamination.
• Be aware that once you create a sterile field, you are responsible for performing the
procedure without contaminating the field and for stopping the procedure if a break in
sterile technique occurs.
1. Verify the health care provider’s orders.
2. Gather the necessary equipment and supplies.
3. Perform hand hygiene, using an alcohol-based hand rub or antimicrobial soap and water.
4. Introduce yourself to the patient and family, if present.
5. Provide for the patient’s privacy.
6. Apply personal protective equipment (PPE) as needed, according to your agency’s policy.
7. Select a clean, flat, dry work surface that is above the level of your waist.
8. Prepare a sterile work surface. If you’re using a sterile commercial kit or pack containing
sterile items:
a. Place the package on a clean, dry, flat work surface above the level of your waist.
b. First open the outside cover and remove the package from the dust cover. Place the
package on the work surface.
c. Grasp the outer surface of the tip of the outermost flap.
d. Open this flap away from your body, keeping your arm outstretched and away from the
sterile field. Do not touch any part of the sterile wrap except the 1-inch margin around
the edge, which is considered to be contaminated.
e. Grasp the outside surface of the edge of the first side flap.
f. Open the side flap, pulling it to the side and allowing it to lie flat on the table. Keep your
arm to the side, not over the sterile field.
g. Now open the second side flap. Open this flap by pulling it to the side and allowing it to
lie flat on the table. Keep your arm to the side, not over the sterile field.
h. Grasp the outside border of the last, innermost flap. Stand away from the sterile package,
and pull the flap back, allowing it to fall flat on the table.
9. After the procedure, help the patient into a comfortable position, and place toiletries and
personal items within reach.
10. Place the call light within easy reach, and make sure the patient knows how to use it to
summon assistance.
11. To ensure the patient’s safety, raise the appropriate number of side rails and lower the
bed to the lowest position.
12. Dispose of used supplies and equipment. Leave the patient’s room tidy.
13. Remove and dispose of gloves, if used. Perform hand hygiene.
14. Document and report the patient’s response and expected or unexpected outcomes.
PERFORMING STERILE GLOVING

ALERT
• Choose latex-free or synthetic gloves if the nurse or patient is allergic to latex, is at high
risk for latex allergy, or has a suspected sensitivity to latex.
• Do not use gloves from a torn or wet package of sterile gloves. The gloves in such a
package are considered contaminated. Signs of water stains on the package indicate
previous contamination by water.
• Select the proper glove size. The gloves should not stretch so tightly over the fingers that
they tear easily, but they must be tight enough to pick up objects easily. There is less
chance of contamination if you wear the correct glove size.
• Interlock your fingers, and hold your hands together in front of your body and above the
level of your waist while waiting to handle sterile items.
PROCEDURE:
15. Gather the necessary equipment and supplies. Select the correct size and type of gloves.
Examine the package to ensure that it’s intact and dry.
16. Perform hand hygiene, inspecting the condition of your hands and fingernails. Look for
any cuts or lesions.
17. To apply gloves:
i. Remove the outer wrapper of the glove package by carefully separating and peeling
apart the sides of the package.
j. Grasp the inner package, and lay it on a clean, dry, flat surface that is at waist level. Open
the package, keeping the gloves on the inside surface of the wrapper.
k. Identify the right and left glove. Each glove has a cuff that is about 5 cm (2 inches) wide.
You will glove your dominant hand first.
l. With the thumb and the first two fingers of your nondominant hand, grasp the glove for
your dominant hand by touching only the glove’s inside surface.
m. Carefully pull the glove over your dominant hand, leaving a cuff. Be sure that the cuff
does not roll up around your wrist and that your thumb and fingers are in the proper
spaces.
n. With your gloved dominant hand, slip the fingers underneath the cuff of the second
glove. Do not touch the top surface of the cuff with your gloved hand, as this will break
the sterile field.
o. Carefully pull the second glove over your nondominant hand.
p. After the second glove is on, interlock your hands above the level of your waist. The cuffs
will usually fall down after application. Be sure to touch only the sterile sides.
18. To dispose of gloves:
q. Grasp the outside of one cuff with the other gloved hand; avoid touching the wrist.
r. Pull the glove off, turning it inside out and placing it in your gloved hand.
s. Take the fingers of your bare hand and tuck them inside the cuff of the remaining glove.
Peel the glove off inside out and over the glove you just removed. Discard both gloves in
the trash receptacle.
t. Perform thorough hand hygiene.
CHANGING A DRESSING

ALERT
• When a dry dressing inadvertently adheres to a wound, minimize trauma by moistening the
gauze with sterile normal saline or sterile water before removing the dressing.
• In a moist-to-dry dressing, allow the inner primary dressing to dry and adhere to
underlying tissues; moistening the dressing is a common error in technique that reduces the
amount of debris the dressing removes.
• Discard solutions 24 to 48 hours after opening, and replace them with fresh solutions that
are clearly labeled with the date and time of opening.
• Use sterile scissors to cut the amount of dressing needed to pack a wound. Pour the
prescribed solution over the packing gauze or strip to moisten it. Do not let the strip touch
the bottle. To avoid trauma during dressing removal, do not overpack the wound.
• If the wound appears inflamed and tender, begins draining, or has an odor, monitor the
patient for signs of infection, notify the health care provider, and obtain a culture.
• If the wound bleeds during a dressing change, observe the color and amount of drainage. If
it is excessive, apply a pressure dressing. Obtain vital signs as needed, and notify the health
care provider.
• Use paper or nonallergenic tape, wraps, or mesh instead of adhesive tape in older adults.
Adhesive can irritate their skin or cause it to tear.
19. Perform hand hygiene, and provide for the patient's privacy.
20. Gather the necessary equipment and supplies.
21. Verify the health care provider's orders.
22. Introduce yourself to the patient and family, if present.
23. Identify the patient using two identifiers. Compare the identifiers with the information on
the patient's identification bracelet.
24. Assess pain status while explaining the procedure to the patient.
25. Apply a gown, goggles, and mask if there is a risk of spray.
26. Position the patient comfortably, and drape him or her to expose only the wound site.
Instruct the patient not to touch the wound or the sterile supplies.
27. Place a disposable biohazard bag within reach of your work area. Fold the top of the bag to
make a cuff.
28. Apply clean disposable gloves.
29. To remove the tape, pull it parallel to the skin, toward the dressing, as you hold down the
uninjured skin. Pull in the direction of any hair growth. If necessary, secure the patient's
permission to clip or shave the area according to your agency's policy. Remove any adhesive
from the skin.
30. With a clean, gloved hand or forceps, remove the old dressing one layer at a time. Observe
the appearance of any drainage. Discard the outside dressing first. Work slowly and
carefully to avoid placing tension on any drainage devices. Keep the soiled underside of the
dressings out of the patient's sight.
31. Fold the dressing so that the drainage is contained inside it, and remove your gloves inside
out. If the dressing is small, pull one of your gloves inside out over the dressing.
32. Dispose of the gloves and soiled dressing according to your agency's policy. Perform hand
hygiene. Apply clean gloves.
33. Inspect the color and integrity of the wound. Look for edema, exudate, and loss of skin
integrity. Observe the skin around any drainage devices. Assess for odor. Apply sterile
gloves, and gently palpate the edges of the wound to determine whether the patient's pain
has increased and to assess for drainage and bogginess. Measure the length, width, and
depth of the wound if indicated.
34. Dispose of gloves and perform hand hygiene.
35. Create a sterile field on the overbed table, using a sterile dressing tray or individually
wrapped sterile supplies.
36. Apply sterile gloves, or apply clean gloves and use sterile forceps for a no-touch technique,
depending on the status of the wound and on agency policy.
37. To cleanse the wound:
u. Use an antiseptic swab for each cleansing stroke, or spray the wound surface with
antiseptic.
v. Cleanse from the least contaminated area to the most contaminated.
w. If a drain is present, cleanse around it using circular strokes. Begin near the drain
and move outward, away from the insertion site.
38. Use dry gauze to blot the wound dry, working from the least contaminated area to the most
contaminated area. If the patient has a drain, blot around it using circular strokes, beginning
near the drain and moving outward and away from the insertion site.
39. Apply an antiseptic ointment, if ordered, using the same technique used to cleanse the
wound.
40. To apply a dressing:
x. Dry dressing:
i. Apply loosely woven gauze as the contact layer.
ii. If a drain is present, apply a pre-cut 4 × 4 gauze to sit flat around the drain.
iii. Apply additional layers of gauze as needed.
iv. Apply a thicker woven pad, such as a Surgipad or abdominal
dressing.
y. Moist-to-dry dressing:
v. Pour sterile solution over the opened package of 4 × 4 gauze or place a strip
of fine mesh gauze in a container of the prescribed sterile solution.
vi. Apply sterile gloves.
vii. Wring out the excess solution.
viii. Apply the moistened fine-mesh, open-weave gauze as a single layer
directly onto the surface of the wound. If the wound is deep, use your sterile
gloved hand or forceps to gently pack the gauze into the wound until all
wound surfaces are in contact with the moistened gauze. Ensure that any
dead space from sinus tracts, undermining, or tunneling has been loosely
packed with gauze.
ix. Do not let the gauze touch the skin around the wound. Fill the
wound, but avoid packing it too tightly or allowing the gauze to extend
beyond the top of the wound.
x. Apply a dry, sterile gauze pad over the wet gauze.
xi. Cover the wound with an ABD pad, Surgipad, or gauze.
41. Secure the dressing with rolled gauze for circumferential dressings; with tape, Montgomery
ties, or straps applied perpendicular to the wound; or with a binder.
42. Label the dressing per the organization’s practice.
43. Remove any personal protective equipment used. Apply clean gloves to dispose of soiled
supplies.
44. Dispose of used supplies and equipment.
45. Help the patient into a comfortable position, and place toiletries and personal items within
reach.
46. Place the call light within easy reach, and make sure the patient knows how to use it to
summon assistance.
47. To ensure the patient's safety, raise the appropriate number of side rails and lower the bed
to the lowest position.
48. Remove and dispose of gloves, if used. Perform hand hygiene.
49. Document and report the patient's response and expected or unexpected outcomes.
COLLECTING A SPECIMEN FOR WOUND CULTURE
 ALERT
• Deliver specimens to the laboratory within the recommended time, or ensure that they
are stored properly for later transport.
• Know your agency’s policy regarding infection control practices for the transport of all
specimen containers containing body substances.
• Be alert for localized inflammation, tenderness, and warmth at a wound site with
purulent drainage, indicating that the wound has become infected.
• Observe for redness and bleeding around the edges of a wound, which may indicate
wound trauma.
• Instruct the patient to inform you if the procedure causes pain. Stop if the patient is
unable to tolerate the pain.
50. Verify the health care provider’s orders.
51. Gather the necessary equipment and supplies.
52. Perform hand hygiene.
53. Provide for the patient’s privacy by drawing the bedside curtain or closing the door.
54. Introduce yourself to the patient and family, if present.
55. Identify the patient using two identifiers, such as the patient’s name and birth date or
name and account number, according to your agency’s policy. Compare the identifiers on
the medication administration record (MAR) with the information on the patient’s
identification bracelet, and/or ask the patient to state his or her name.
56. Before collecting a wound drainage specimen for culture and sensitivity testing, assess
the patient for sign and symptoms of infection such as fever, chills, and excessive thirst.
57. Ask patient to rate his or her pain at the wound site.
58. Apply clean gloves. Remove the old dressing, and assess it for exudate and drainage. Fold
the soiled sides of the dressing together, and dispose of it in the appropriate receptacle.
59. Remove your gloves and apply sterile gloves for assessment.
60. Assess the wound by looking for swelling, separation at the edges of the wound,
inflammation, and drainage.
61. Cleanse the area around the wound edges with an antiseptic swab, moving from the
edges outward. Wipe away all of the old exudate.
62. Discard the swab, and remove and dispose of your soiled gloves in the appropriate
receptacle. Perform hand hygiene.
63. Open the packages containing the sterile culture tube and dressing supplies. Apply a new
set of sterile gloves.
64. Obtain cultures:
z. To obtain an aerobic culture:
xii. Remove the swab from the culture tube, gently insert the tip of the swab into the
wound in the area of fresh drainage, and gently rotate the swab. Return the swab to the
culture tube.
aa. To obtain an anaerobic culture:
xiii. Take the swab from the special anaerobic culture tube. Insert the swab deeply into
the draining body cavity, and gently rotate the swab. Withdraw the swab and return it to
the culture tube.
xiv. Another method would be to insert the tip of a syringe, without a needle, into the
wound and aspirate 5 to 10 mL of exudate. Then attach a transfer device to the syringe,
expel all of the air, and inject the drainage into an anaerobic culture tube.
65. Regardless of which method you use, be sure to label each specimen tube and verify
information in front of the patient.
66. Make a notation on the label if the patient is receiving antibiotics.
67. Place the specimen in a biohazard bag. Remove your gloves and dispose of them
properly.
68. Perform hand hygiene.
69. Apply clean or sterile gloves as appropriate, and clean the patient’s wound as required
by the health care provider’s order.
70. Open the dressing supplies and cover the wound with a new sterile dressing. For more
information refer to the skill video “Changing a Dressing.”
71. Remove and dispose of the used gloves and soiled supplies in the appropriate receptacle,
according to your agency’s policy. Perform hand hygiene.
72. Help the patient into a comfortable position, and place toiletries and personal items
within reach.
73. Send the specimen to the laboratory immediately.
74. Place the call light within easy reach, and make sure the patient knows how to use it to
summon assistance.
75. To ensure the patient’s safety, raise the appropriate number of side rails and lower the
bed to the lowest position.
76. Leave the patient’s room tidy.
77. Document and report the patient’s response and expected or unexpected outcomes. As
part of your follow-up care, review the culture and sensitivity test results when they
come back from the lab.
ESTABLISHING AND MAINTAINING A STERILE FIELD
 ALERT
• It is the nurse’s responsibility to stop a procedure when a break in sterile technique
occurs.
• Gain the patient’s full cooperation in order to minimize contamination of your work
area.
• Explain to the patient how you will perform the procedure and what he or she can do to
avoid contaminating sterile items, such as avoiding sudden body movements, refraining
from touching sterile supplies, and avoiding coughing or talking over a sterile area.
• Teaching the patient before you perform a sterile procedure minimizes the need to talk
during the procedure, which can cause air droplet contamination of a sterile area.
• Traffic or movement can increase the potential for contamination by spreading
microorganisms on air currents.
78. To prepare a sterile field, begin by checking the expiration date on the sterile packaging.
Look for punctures, tears, stains, and evidence of moisture.
79. Gather the necessary equipment and supplies.
80. Apply personal protective equipment (PPE) as needed, according to your agency’s policy.
81. Perform hand hygiene thoroughly, using an alcohol-based hand rub or an antimicrobial
soap and water.
82. Select a clean, flat, dry work surface that is above your waist level.
83. To prepare a sterile field from a drape:
bb. Place the sterile kit containing the sterile drape on a clean, dry, flat work surface above
the level of your waist. You may touch the outer 1-inch border of the drape without
wearing gloves.
cc. Open the outside cover of the kit. Remove the kit from outside cover, discard the cover,
and place the kit on the work surface. Grasp the folded top edge of the drape with the
fingertips of one hand.
dd. Gently lift the drape from its wrapper without allowing it to touch anything. Do not reach
over the sterile field.
ee. Let the drape unfold holding it away from your body and keeping it above your waist and
the work surface.
ff. Then grasp the adjacent corner of the drape and hold it straight over your intended work
surface.
gg. Position the bottom half of the drape over the top half of the work surface. Then allow
the top half of the drape to cover the bottom half of the work surface. This creates a flat
sterile field for placement of sterile supplies.
hh. REMEMBER: The outer 1-inch perimeter of the drape is not considered sterile. You can
touch this border without wearing gloves.
84. To prepare a sterile work surface with a sterile linen-wrapped package:
ii. Place the package on a clean, dry, flat work surface above the level of your waist.
jj. Remove the sterilization tape seal, and unwrap both layers:
xv. First open the outside cover and remove the package from the dust cover. Place the
package on the work surface.
xvi. Grasp the outer surface of the tip of the outermost flap.
xvii. Open this flap away from your body, keeping your arm outstretched and away from
the sterile field.
xviii. Grasp the outside surface of the edge of the first side flap.
xix. Open the side flap, pulling it to the side and allowing it to lie flat on your work
surface. Keep your arm to the side, not over the sterile field.
 xx. Now open the second side flap. Open this flap by pulling it to the side and allowing
it to lie flat on the table. Keep your arm to the side, not over the sterile field.
xxi. Grasp the outside border of the last, innermost flap. Stand away from the sterile
package, and pull the flap back, allowing it to fall flat onto your work surface.
kk. Use the opened package wrapper as a sterile field.
85. To maintain a sterile field, remember these principles:
ll. A sterile object remains sterile only if objects that touch it are also sterile.
mm. A sterile object becomes contaminated when touched by any nonsterile object.
nn. If your hands or a sterile object drop below waist level, both are considered
contaminated.
oo. A sterile field becomes contaminated if moisture permeates the field.
86. To maintain the sterile field:
pp. Avoid reaching across the sterile field.
qq. Never turn your back on a sterile field.
rr. Never leave the room after a sterile field has been set up.
87. Throughout the procedure, observe for any break in the sterile field.
88. If a break occurs, set up a new sterile field.
IRRIGATING WOUNDS
 ALERT
• Perform meticulous hand hygiene, and follow proper infection control procedures
before and after removing soiled dressings. Wear clean gloves during wound care.
• Use sterile irrigation solution for postoperative wounds. Use clean solution for chronic
wounds.
• Irrigate so that the solution flows from the least contaminated area (healthy tissue)
toward the most contaminated area (infected tissue), and from the area being cleansed
to a lower, distal area.
• Consider using a handheld shower technique for wound cleansing in an ambulatory
patient, keeping the shower head about 12 inches from the wound.
• Never substitute a skin cleanser for a wound cleanser; they are not the same.
• Do not force a catheter into the wound. Place the syringe carefully to keep the pressure
of the flowing solution from becoming too high.
• Consider culturing a wound if it has a foul odor, becomes inflamed, or begins to drain, or
if the patient becomes febrile.
• If bleeding occurs, serosanguineous drainage appears, or the suture line on a surgical
wound opens or extends, flush with less pressure during the next irrigation. Notify the
health care provider of the bleeding.
89. Before irrigating a wound, check to see what kind of solution the provider has specified
in the order.
90. Gather the necessary equipment and supplies.
91. Perform hand hygiene, and provide for the patient’s privacy.
92. Introduce yourself to the patient and family, if present.
93. Identify the patient using two identifiers, such as the patient’s name and birth date or
name and account number, according to your agency’s policy. Compare the identifiers
with the information on the patient’s identification bracelet.
94. Check prior nursing notes for previous wound assessments.
95. Form a cuff on a waterproof biohazard bag, and place it near the bed.
96. Apply clean gloves. Adjust the patient’s gown and bedding to expose the wound only.
Remove the dressing and dispose of properly.
97. Assess the wound before you begin irrigation. Refer to the video skill “Assessing
Wounds.”
98. Wear a gown and goggles to protect yourself from any splashes or spray.
99. Place a container of irrigant/cleansing solution in a basin of hot water to warm the
solution to body temperature.
100. Position the patient to permit gravitational flow of the irrigation solution into the
collection receptacle. The wound should be perpendicular to the collection basin.
101. Protect the bedding by slipping a waterproof pad or an extra towel under the
patient.
102. Open the irrigation kit and apply sterile gloves.
103. To irrigate a wound with a wide opening:
ss. Fill a syringe with the prescribed irrigation solution.
tt. Attach a sterile 19-gauge angiocatheter or sterile 19-gauge needle to the syringe.
uu. Set the collection basin on the pad.
vv. Hold the syringe tip 2.5 cm (1 inch) above the upper end of the wound.
ww. Using steady, continuous pressure, flush the wound. Refill the syringe, and continue
flushing until the solution that drains into the collection basin is clear.
104. To irrigate a deep wound with a very small opening:
xx. Use an already prepared catheter syringe or attach a soft catheter to a filled irrigation
syringe.
yy. Gently insert the catheter tip into the wound opening to a depth of 1 cm (about 0.5 inch).
zz. Flush the wound using slow, continuous pressure.
aaa. Move the syringe around being sure to irrigate all parts of the wound. As you
irrigate, be sure not to contaminate other aspects of the wound.
bbb. Refill the syringe if necessary. As with a shallow wound, you will continue to
irrigate until the solution from the wound is clear.
105. To irrigate a wound with a handheld shower:
ccc. Perform hand hygiene, and apply clean gloves. With the patient seated comfortably in a
shower chair, adjust the shower spray to a gentle flow of warm water.
ddd. Hold the shower head 30 cm (12 inches) from the wound, and flush the wound for 5
to 10 minutes.
eee. Dry the patient after his or her shower, and help the patient dress and return to
bed.
106. When indicated, obtain wound cultures after cleansing the wound.
107. Dry the wound edges with gauze.
108. Apply the appropriate dressing, label it with the time and date, and initial it.
109. Remove your personal protective equipment.
110. Apply clean gloves. Dispose of all used equipment and soiled supplies. Leave the
patient’s room tidy.
111. Remove your gloves, and perform hand hygiene.
112. Help the patient to a comfortable position, and place toiletries and personal items
within reach.
113. Place the call light within easy reach, and make sure the patient knows how to use
it to summon assistance.
114. To ensure the patient’s safety, raise the appropriate number of side rails and lower
the bed to its lowest position.
115. As part of your follow up care, inspect the dressing periodically according to agency
policy.
116. Document and report the patient’s response and expected or unexpected
outcomes, characteristics of the wound, any drainage, and cultures obtained according to
agency policy.