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Latter half of 19th century, many surgeons continued
to perform surgical procedures while wearing street clothes under pus- and blood-encrusted aprons despite the expansion of germ theory knowledge. The first use of caps and sterile gowns occurred in Germany while English surgeon Joseph Lister’s (18271912) principles of antiseptic surgery were still being debated. The use of sterile gowns antedated the routine use of caps, gloves and masks, although in 1883 Gustav Neuber (28500-1932) insisted that team members wear caps also. Various styles of turbans and shower cap-style head coverings were worn from about 1908 to the 1930s, when hair was generally acknowledged to be an attraction for and shedder of bacteria.
Rubber surgical gloves were introduced. William Halsted (1852-1922). not to protect the patient but to protect the wearer’s hands from the harsh. designed a semicircular instrument table to separate himself . The use of gloves was not popularized until the 1890s. in sterile gown and gloves. Gauze masks were advocated by Johann von Mikulicz in 1897. It was not until 1926. complained dermatitis. from observes in street clothes who watched him operate. that masks become obligatory. when Halsted’s scrub nurse. chief . American surgeon of surgery at Johns Hopkins. In 1897. when wound infections yielded the same organisms as found in the nose and throats of surgeons and nurses. when the droplet theory of infection was demonstrated. irritating antiseptic solutions and hand soaks of 1870s and 1880s. Caroline Hampton (whom he later married).
the scrub nurse wore both a mask and a gown. OR personnel were required to change shoes when entering the OR suite and to wear those shoes only when within the suite. and a gown with a pocket for a pad and pencil. full skirts were replaced by closefitting scrub dresses and pantsuits that reduced the hazard of brushing against a sterile table when near or passing by it. By the 1930s and 1940s. . as safety restrictions became more rigid. In 1924 one of the surgical nursing texts described the attire of the OR nurses: the circulator wore an OR cap. heretofore worn under the sterile gown. In 1950.1n 1960s. but had extra pockets in front for the surgeons instruments. but no mask. scrub dresses began to replace nurses’ regular uniforms.
they are almost completely removed by thorough washing with soap or detergent and water.SURGICAL SCRUB and HAND CLEANSING Microbiology of the Skin The skin is inhabited by the following organisms: Transient organisms acquired by direct contact. Two processes are commonly used: 1. In scrubbing. They are more adherent and therefore more resistant to removal.Chemical. Resident organisms below the skin surface in hair follicles and in sebaceous and sweat glands. The process reduces resident florae and inactivates microorganisms with an antimicrobial or antiseptic agent. Mechanical. 2. the skin is skin is cleaned of as many microorganisms as possible. Usually loosely attached to the skin surface. The process removes soil and transient organisms with friction. .
debris. . natural skin oils.Purpose The purpose of surgical hand and arm cleansing is to remove or deactivate soil. and transient microorganisms from the hands and forearms of sterile team members. To keep the population of microorganisms minimal during the surgical procedure by suppression of growth. More specifically. the purposes are as follows: To decrease the number of resident microorganisms on skin to an irreducible minimum. hand lotions. To reduce hazard of microbial contamination of the surgical wound by skin florae.
They should not be used to clean or rinse contaminated instruments or equipment. It should be used only for scrubbing or handwashing. Individually enclosed scrub sinks with automatic sensor controls or foot-orknee-operated faucets are preferred to eliminate the hazard of contaminating the hands after cleansing. wide.Scrub Sink The scrub room is adjacent to the OR for safety and convenience. The sink should be deep. and low enough to prevent splash. .
each brush should be removed without contaminating others. The scrubbing solution is dispensed onto the brush sponge pr sponge by a foot pedal from a container attached or adjacent to the sink. . Sterilized reusable scrub brushes or disposable sponges may be used. Biologic material may be difficult to remove from reusable brushes. Single-use disposable products may be brush-sponge combination and are preferred. Orangewood sticks are not used to clean under the fingernails. If reusable brushes are taken from the dispenser in which they were sterilized. single-use disposable nail cleaning products are available and are usually supplied with disposable scrub brushes. because the wood may splinter and harbor Pseudomonas organisms. Six drops of solution (2-3 ml) is sufficient to generate a lather for the scrub procedure.Equipment Plastic.
The following are desirable characteristics of antimicrobial agents: Broad spectrum Fast-acting and effective Nonirritating and nonsentisizing Prolonged action Independent of cumulative action Frequent cleansing with the same agent tends to inhibit reestablishment of resident florae. The Centers for Disease Control and Prevention (CDC) indicates the most of the studies performed to date have focused on measuring hand bacterial counts and not focused on the impact of any scrub agent choice on surgical-site infection.Antimicrobial Skin-Cleansing Agent Various antimicrobial (antiseptic) detergents are used for surgical hand washing. .
5%. Parachlorometaxylenol. It is available in 10%.5% in alcohol exerts an antimicrobial effect against gram-positive and gramnegative. Hexachlorophene. hexachlorophene is most effective after buildup of cumulative suppressive action. Alcohol. A povidine-iodine complex in detergent fulfils the criteria for an effective surgical scrub. fungal.75%. Triclosan.5 %. Ethyl or isoprophyl alcohol(60% to 90%) is rapidly antimicrobial against all microorganisms. intermediate antimicrobial agent that inhibits inhibits growth of a wide range of gram-positive and gram negative and TB microorganisms. Chlorhexidine Gluconate. 2% and 0. nonirritating. parachlorometaxylenol does not substantially reduce microorganisms immediately. In concentration up to 3%. Used in a concentration of 1% to 3. Iodophor. A solution of 1% triclosan is nontoxic. and viral microorganism. 7. A 4% aqueous concentration of chlorhexidine gluconate (CHG) in a soap base or 0. .
a non-oil based product is recommended. 4. 3. Fingernails should not reach beyond the fingertip to avoid glove puncture. and neck. Artificial nails harbour microorganisms such as bacteria and fungi. Artificial devices should not cover natural fingernails. wrists. Fingernail polish should not be chipped or cracked. Freshly applied may be worn if permitted by facility policy. .Preparation for Surgical Hand Cleansing General Prepartion 1. 2. If hand lotion is used to protect the skin. All jewelry should be removed from the fingers. Jewelry harbour microorganisms. Oil can weaken the integrity of gloves. 5. The skin and nails should be kept clean and in good condition. and the cuticles should be uncut.
Open sterile gown and gloves on a separate surface from the main sterile field. Adjust protective eyewear or the face shield comfortably in relation to the mask. Clean eyeglasses if worn. 2.Preparations Immediately before Surgical Hand Cleansing 1. 6. 5. Be sure all hair is covered by headwear. 3. . 4. Pierced-ear studs should be contained by the head cover. Skin integrity of the hands and forearms should be intact. Adjust the disposable mask snugly and comfortably over the nose and mouth. Adjust water to a comfortable temperature. Inspect the hands for cuts and abrasions. They are a potential foreign body in the surgical site.
A counted brush-stroke method is equally effective in decreasing the microbial count in the skin. When gloves are removed at the end of the surgical procedure. Every member of the surgical team should scrub according to a standardized written procedure.to 5.minute scrub with a reliable agent is effective. the hands are considered contaminated and should be immediately washed. . Too short a scrub may be equally ineffectual.Surgical Hand and Arm Scrub with a Brush A vigorous 2.
ending 2 inches above the elbow. then the palmar surface of the hand. . Persons who scrub should think of their fingers. from the small finger to the thumb. During and after scrubbing. over the dorsal (back) surface of the hand. in thirds. Because the hands are in most direct contact with the sterile field.to the marginal area of the upper arms. beginning with the thumb and moving from one finger to the next. down the outer edge of the fifth finger. keep the hands higher than the elbows to allow water and suds to flow from the cleanest area-the hands. all steps of the scrub process begin with cleaning the fingernails and hands and ends with the elbows. over the wrists and up the arm. Both method follow an anatomic pattern of scrubbing: the four surfaces of each finger. and arms as having four sides or surfaces. or vice versa. hands.
Brushless/Waterless Surgical Hand Cleansing Most brushless cleansing agents have an alcohol base with an antimicrobial ingredient such as CHG or triclosan. . Care is taken to allow the agent to completely dry before donning the sterile gown and gloves.
usually the scrub person. Lift the gown. 2. Do not hand a gown from a back table when the case is in progress. and lay one end on the freshly scrubbed team member’s hand. The drapes and gowns on the field in progress are considered biologically contaminated and could contaminate the wearer. Open the hand towel. holding it open at the shoulders and neckline by cuffing over the hands. . may assist the surgeon or another team member in gowning and gloving by taking the following steps: 1. being careful not to touch the hand. and unfold it carefully with the sterile outside toward you and the unsterile inside toward the person being gowned. Do not hand a towel from a bloody back table or hand a towel with contaminated gloves.ASSISTED GOWNING AND GLOVING OF A TEAM MEMBER A team member in sterile gown and gloves.
Keeping your hands on the sterile side of the gown under a protective cuff of the neck and shoulder area. . In doing so. The team member holds arms outstretched while the circulator pulls the gown onto the shoulders and adjusts the sleeves so that the cuffs are properly slid back to expose the hands. Release the gown when it is secured by the person being gowned. offer the inside of the gown for the team member to don. the circulator touches only the inside of the gown at the seams.3. Take care not to let the sleeves make contact with unsterile areas 4. He or she slips the arms into the sleeves.
2.GLOVING A TEAM MEMBER Pick up the right glove. Stretch the cuff sufficiently open for the other to introduce the right hand. . 4. 1. Exert upward pressure as the person slides the hand into the glove. Pull the glove cuff up and over the cuff of the right sleeve. and grasp it firmly with the fingers of both hands under the everted cuff on the sterile side. 3. avoid touching the hand by holding your thumbs out. Hold the palm of the glove toward the person being gloved.
The person being gloved can facilitate the process by supinating the gloved right hand and flexing the fingers like a hook to hold open the cuff of the glove being donned. Be careful not to contaminate the gloves at the neck level. assist the person to tie in. If a sterile vest is needed.5. If the gown is a wraparound. . hold it for the surgeon to slip the hands onto the armholes. Repeat for the left hand. Remember that the back of the gown is not considered sterile even if a sterile vest is worn. 6.
. In pulling gown off arms. With gloves on. 2. 3. and gown is removed entirely by pulling it off inside out and rolling it away from the body. Clean arms and scrub suit are protected from contaminate outside of the gown. The gown is removed before the gloves. The gown is removed as follows: 1. Do not reach behind the gown to untie the back strings.REMOVING OR CHANGING CONTAMINATED GOWN AND GLOVES The contaminated team member steps away from the field. be sure that gown sleeve is turned inside out to prevent contamination of scrub attire. The contaminated person grasps the front of the gown at the shoulders below the neckline. and the circulator unfastens the neck and waist ties of the soiled gown. The other shoulder is grasped with the other hand. grasp the front shoulder of gown and pull forward .
The gloves are removed as follows: 1. then skin-to skin technique is used to protect the clean hands from the contaminated outside of the gloves. and pull it off inside out.The gloves are removed using a glove-to glove and then skin-to-skin technique. Wash hands. . A glove-to glove. 4. 3. 2. Grasp the cuff of the left glove with the gloved fingers of the right hand. Slip the ungloved fingers of the left hand under the cuff of the right glove. and slip it off inside out. which bear blood and body fluid of the patient. Discard the gloves in a trash receptacle. The cuffs of the gloves usually turn down as the gown is pulled off the arms.
Preferably. wearing protective gloves. If stepping away immediately is not feasible. Extend the contaminated hand to the circulator who. grasp the contaminated objects and sets them aside. toward the palm and pulls the glove off inside out. . If this is not possible. The glove is changed as follows: 1. using the open gloving technique. Turn away from the sterile field. it must be changed immediately. 2.CHANGING GLOVES DURING THE SURGICAL PROCEDURE If a glove becomes contaminated for any reason during a surgical procedure. 3. a sterile team member gloves another. The circulator then grasps the outside of the contaminated glove cuff about 2 inches below the top of the glove. the contaminated hand and any object involved in the contamination should be held away from the sterile area. step aside and glove the hand.
The closed gloving technique is inappropriate for a glove change during a surgical procedure. . the scrub person should change his or her own gloves before gowning and gloving another team member to avoid exposing the team member to contamination. because contamination of the new glove by the cuff of the gown is inevitable.
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