I.

MEDICAL ASEPSIS

HAND HYGIENE
- hand hygiene is the most effective way to help prevent the spread of
organisms
- applies to either hand washing with plain soap and water, use of antiseptic
handrubs including alcohol-
based products, or surgical hand antisepsis
- important to clean hands promptly: when they are visibly soiled, after
each contact with contaminated
materials, after removing gloves

1. BACTERIAL FLORA ON HANDS

a. Types
i. Transient Bacteria
- normally picked up by the hands in the usual activities of daily
living
- relatively few in number and type on clean and exposed areas of
the skin
- attached loosely, usually in grease, fats, and dirt (found in
greater numbers under the
fingernails)
- pathogenic and nonpathogenic can be removed with relative
ease by washing the hands
thoroughly and frequently
- may adjust to environment when present in large numbers and
over a long period of time
become resident

ii.Resident Bacteria
- normally found in creases in the skin (relatively stable in
number and type)
- cling tenaciously to the skin by adhesion and absorption,
requiring considerable friction
with a brush for removal
- less susceptible to antiseptics

2. CLEANSING AGENTS
a. Types
i. Nonantimicrobial Agents
- soaps and detergents (bar, liquid, leaflet, and powdered)
- considered adequate for routine mechanical cleansing of the
hands and removal of most
transient microorganisms
- lower surface tension and act as emulsifying agents

ii. Antimicrobial Agents - can kill bacteria or suppress their growth

- recommended in any setting where the risk for infection is high
 - alcohol-based handrubs are more effective in reducing bacterial
counts, thus reducing
nosocomial spread of disease
- alcohol-based handrubs have an alcohol concentration between
60% and 90%
- available as foam, gel, or lotions
- save time - do not require a sink - easily available in
patient care areas

Disadvantages: can cause skin irritation and dryness which

defeats the purpose of the
product in decreasing the number of surface
organisms because damaged
skin harbors organisms and is more difficult to clean
adequately
- alcohol-based handrubs containing emollients
address these concerns
- lotions, applied after patient care, may also be used
to soothe damaged
skin (oil-based lotions may adversely affect the
integrity of latex
gloves)
3. RECOMMENDED TECHNIQUES
- if hands are visibly soiled or contaminated with blood or body fluids,
washing with soap and water is
required
- if hands are not visibly soiled, an alcohol-based handrub can be used
- effective Handwashing requires at least a 15-second scrub with plain
soap or disinfectant and
warm water
- visibly soiled need a longer scrub
- recommended all jewelry (where bacteria tend to accumulate) except
wedding bands be removed
- rings also increase the likelihood that gloves may tear when
donned
- nails are to be kept short, with close attention to the area beneath the
fingernails
- polish doesn’t appear to increase numbers of microorganisms as
long as it’s not chipped
- clear polish is preferable to color
- artificial nails are not recommended because they harbor more
bacteria than natural nails,
place the wearer at risk for developing a fungal infection in
the nail bed and are
associated with less vigorous scrubbing in the nail area
- wearing gloves does not eliminate the need for proper hand hygiene
- warmth and moisture inside gloves create an ideal environment
for bacteria to multiply
 - gloving does not guarantee complete protection from infectious
organisms
- provides a barrier but are not impenetrable

ACTION RATIONALE
1. Stand in front of sink – Don’t Clothing may carry contamination from
allow clothes place to place
to touch sink during washing
2. Remove jewelry Microorganisms may accumulate in settings
3. Use warm water and medium Water splashed will contaminate clothing.
force Warm water is more comfortable, has less
tendency to open pores and remove oils
from skin. Organisms can lodge in rough,
broken areas of chapped skin
4. Keep hands lower than Water should flow from the cleaner
elbows (forearms) toward contaminated (hands)
5. Apply washing agent (if using Rinsing bar soap removes lather than may
bar, rinse contain microorganisms
soap again and return to soap
dish)
6. With firm rubbing and circular Friction helps loosen dirt / organisms
motions, Length of washing is determined by degree
wash hands, up to at least 1” of contamination
above the
hands (Continue for at least
15 sec.)
7. Use fingernails of other hand Area under nails has a high microorganism
or clean count
orangewood stick to clean
under
fingernails
8. Rinse thoroughly & pat hands Drying and patting the skin well prevents
dry using chapping
paper towels and discarding
immediately
without touching other clean
hand
9. Use lotion, if desired Avoid oil-based lotions – they deteriorate
gloves

CONTROL VIA STERILIZATION AND DISINFECTION

- cleansing, disinfection, and sterilization help to break the cycle of infection
and prevent disease
- items, such as pitchers, water glasses, and plastic basins, may be used
repeatedly but by one patient only,
then discarded or sent home with the patient on discharge
 disinfection – destroys all pathogenic organisms except spores
- can be used when prepping the skin for a procedure or cleaning a
piece of equipment that does not
enter a sterile body part

sterilization – process in which all microorganisms, including spores, are

destroyed
- performed on equipment that is entering a sterile portion of the body

1. FACTORS FOR METHOD SELECTION

a. Nature of organisms present – supplies, linens, and equipment in a
healthcare setting should be
treated as if the patient were infectious
b. Number of organisms present – the more present, the longer it takes to
destroy them
c. Type of equipment – equipment with small lumens, crevices, or joints
require special care
- articles that may be damaged by various sterilization and
disinfection methods require
special handling
d. Intended use of equipment – medical or surgical asepsis influences the
preparation and cleaning
e. Available means for sterilization and disinfection – choice of chemical or
physical means depends on
nature and number of organism, type and intended use of
equipment, availability and
practicality of the means
f. Time – failure to follow recommended time periods is grossly negligent

2. CLEANING OF SUPPLIES AND EQUIPMENT

- wear waterproof gloves at all times
- rinse the article first with cold running water to remove organic
material
- wash the articles, after rinsing them, in warm water that contains
detergent or soap
- use brush with stiff bristles to clean thoroughly
- rinse and dry thoroughly
- prepare the cleaned equipment for sterilization and disinfection
- consider the brush, gloves, sink / basin highly contaminated and treat
or discard accordingly

**Home Care Considerations – after thorough cleaning, some items may be

disinfected by placing them in
boiling water or using common household disinfectants such as bleach,
isopropyl alcohol (70%) or
acetic acid (white vinegar)

3. METHODS
Physical:
 a. Steam – higher temperature caused by higher pressure destroys
organisms (ex. autoclaving)
- most plastic and rubber devices are damaged by autoclaving
b. Boiling Water – simple, inexpensive – frequently used in homes – boil
item for at least 10 minutes
- spores and some viruses are not destroyed by boiling
c. Dry Heat – alternative sterilization method for home – used for metal
items – 350º heated oven for 2
hrs. or more
- insufficient to destroy all microorganisms – not used in
healthcare agencies
d. Radiation – used for pharmaceuticals, foods, plastics, and other heat-
sensitive items
- items must be directly exposed to ultraviolet radiation on all
surfaces – poses risk to
personnel
Chemical:
a. Ethylene Oxide Gas – destroys microorganisms and spores (gases
released with items in autoclave)
- precautions necessary because gas is toxic to humans
b. Chemical Solutions – generally used for instruments and equipment
disinfection and housekeeping
disinfection
- chlorines, sodium hypochlorite (household bleach), betadine and
alcohol are used
- method does not destroy all spores and may cause corrosion on
metal

PERSONAL PROTECTIVE EQUIPMENT (PPE) AND SUPPLIES

A. TRANSMISSION-BASED PRECAUTIONS AND BARRIER TECHNIQUES FOR INFECTION PREVENTION

AND CONTROL
- transfer of pathogens from person to person can be decreased by
limiting the dissemination of
pathogens
- most practical way to accomplish is through the use of barriers that
prevent common vehicles from
transmitting the pathogens

B. PERSONAL PROTECTIVE EQUIPMENT AND SUPPLIES

- check physician’s order for type of precautions and review precautions
in Infection-Control Manual
- mode of transmission or organism determines type and degree
of precautions
- plan nursing activities and gather necessary equipment before
entering patient’s room
- provide instruction about precautions to patient, family members, and
visitors
1. GLOVES
- not a substitute for good hand hygiene
- worn only once then discarded appropriately
- if worn with gown, draw glove cuffs over gown sleeves
- if worn with gown, untie waist strings (considered contaminated)
of gown before removing
gloves
- hands are thoroughly decontaminated with meticulous hand hygiene
- each patient interaction requires a clean pair of gloves
- activities such as turning a patient, feeding a patient, taking vital
signs, and changing IV fluid bags
do not require gloves as long as the potential contact with body
fluids is not present
- while wearing gloves never: leave the patient’s room (unless
transporting a contaminated item
or a patient requiring transmission-based
precautions)
write in a patient’s chart
use the computer keyboard or telephone in the
nurses’ station
- being exposed to body fluids and blood and handling many surgical
instruments are both factors
contributing to glove failure

a. Latex Allergy – sensitivity reactions can range from local skin reactions
to urticaria (hives) to
systemic anaphylaxis (an exaggerated allergic reaction that can
result in death)
- cornstarch powder or talc used to make gloves easier to put on is
a major causative factor
-powder particles may be inhaled, be absorbed into skin or
mucous membranes or
enter the bloodstream
- nitrile gloves (synthetic material that resembles latex but has not
latex protein) tear easily
but provide an alternative to latex
- latex safe environment involves removal or covering of any
natural latex rubber items, such
as wall mounted blood pressure cuffs, sharps containers,
injection port caps on IV
tubing, and urinary catheters
- always ask whether patients have experienced any unusual signs
or symptoms when
blowing up balloons, using latex condoms, or wearing
rubbing gloves for
dishwashing or cleaning

2. GOWNS
 - usually worn to prevent soiling of healthcare worker’s clothing by the
patient’s blood and body fluids
- provide barrier protection and are donned immediately before entering
a patient’s room
- worn only once and then discarded appropriately
- if gown becomes heavily soiled or moistened with blood or body fluids
when caring for a patient,
remove it, perform thorough hand hygiene and put on a clean
gown
- neck strings are considered clean
- gown that is not visibly soiled requires no particular technique for
removal

3. MASKS
- help prevent wearer from inhaling large-particle aerosols, which
usually travel short distances
(about 3 ft) and small-particle droplet nuclei, which can remain
suspended in air and travel
longer distances
- discourage wearer from touching the eyes, nose, and mouth, limiting
contact with mucous
membranes
- worn only once and never lowered around the neck and then brought
back over the mouth and
nose for reuse
- high-efficiency particulate air (HEPA) filter respirator or N95 respirator
certified by NIOSH must be
worn when entering room of patient with known or suspected
tuberculosis
- these respirators filter inspired air (surgical masks filter only
expired air)
- N95 respirator fits more comfortably against the face and costs
considerably less than the
HEPA filter respirators
- elastic straps provide more protection and a better fit than
the ties on regular
surgical masks

4. PROTECTIVE EYEWEAR
- goggles or face shield
- must be available whenever there is a risk of contaminating the
mucous membranes of the eyes
ex. while suctioning a tracheostomy or assisting in an invasive
procedure

5. OTHER SUPPLIES AND PROCEDURES

- used equipment may be disposed of after use or, if reusable, bagged
and sent to a central cleaning
area, and sterilized or disinfected
 - use of paper trays and plastic eating utensils does not prevent
transmission of pathogens and is no
longer recommended
- combined hot water and detergent used in commercial dishwashers
sufficiently decontaminates
dishes, glasses, and utensils
- when collecting a specimen, take care to prevent the outside of the
container from becoming
contaminated
- place all laboratory specimens in plastic bags and seal to prevent
leakage during transport
- bag marked “BIOHAZARDS” is used to dispose of trash
containing liquid or semi-liquid
blood or other potentially infective material (OPIM)

SPECIALIZED INFECTION-CONTROL PRECAUTIONS

isolation – protective procedure that limits the spread of infectious diseases
among hospitalized patients,
hospital personnel, and visitors

CDC recommends that healthcare workers use gloves, gowns, masks, and protective
eyewear when exposure to
blood or body fluids is likely and that all patients should be considered
potentially infected
- blood, semen, vaginal secretions, breast milk, cerebrospinal, synovial,
pleural, peritoneal, pericardial, and
amniotic fluids are included

Body substance isolation precautions consider all body substances potentially

infectious regardless of person’s
diagnosis, advocating the consistent use of barriers whenever healthcare
personnel have contact with moist
body substances, mucous membranes and nonintact skin
- include not only blood and blood-tinged fluids but also feces, urine, wound
drainage, oral secretions,
vomitus, and any other body substances
- varicella (chickenpox), influenza, and pulmonary tuberculosis are examples
of airborne diseases that
require a private room with a door closed and a “Stop Sign Alert”
- mask use depends on the organism and visitor’s immune status
- body substance isolation precautions also provide a consistent approach to
soiled linen, trash disposal, and
laboratory specimens

STANDARD PRECAUTIONS – precautions used in the care of all hospitalized individuals

regardless of their diagnosis or
possible infection status
 - apply to blood, all body fluids, secretions, and excretions except sweat
(whether or not blood is present or
visible), nonintact skin and mucous membranes

Techniques: wear clean nonsterile gloves and PPE

avoid recapping needles
handle patient care equipment that is soiled with blood or
identified body fluids, secretions,
and excretions carefully
use adequate environmental controls
review room assignments carefully

TRANSMISSION-BASED PRECAUTIONS – precautions used in addition to standard precautions

for patients in hospitals
with suspected infection with pathogens that can be transmitted by airborne,
droplet or contact routes
- encompass all the diseases or conditions previously listed
- recognizes that a disease may have multiple routes of transmission

Techniques: in addition to standard precautions

Airborne – for infections spread through the air
- place patient in private room that has monitored negative air
pressure
- use respiratory protection
- transport patient out of room only when necessary and with a
surgical mask on the patient
- consult CDC Guidelines for additional preventions regarding
tuberculosis

Droplet – for infections spread by large-particle droplets

- use private room (door may remain open)
- wear a mask when within 3 ft. of patient
- transport patient out of room only when necessary and with a
surgical mask on the patient
- keep visitors 3 ft. from infected person
Contact – for infections spread by direct or indirect contact
- use private room
- wear gloves
- wear gown if contact with infectious agent is likely
- limit movement of patient out of room
- avoid sharing patient-care equipment (blood pressure cuff,
stethoscope, thermometer, etc)

SPECIAL SITUATIONS
Methicillin Resistant Staphylococcus Aureus (MRSA)
Vancomycin Resistant Enterococcus (VRE)
- use standard and transmission-based (particularly contact) precautions
- avoid wearing rings, bracelets, or watches
 Immunosuppressed Patients – more often than not become infected by
organisms harbored in their own
bodies rather than pathogens present in the environment or transmitted
from other people
- provide a healthy healthcare provider
- restrict visits from friends and family who have colds or contagious
illnesses
- avoid standing collection of water in the room

II. SURGICAL ASEPSIS

-procedures that involve the insertion of a urinary catheter, sterile
dressing changes, or preparing an
injectable medication are examples of surgical asepsis techniques
- object is considered sterile when all microorganisms, including
pathogens and spores, have been
destroyed
- observing medical asepsis, areas are considered contaminated if they
bear or are suspected of
bearing pathogens
- observing surgical asepsis, areas are considered contaminated if they
are touched by any object
that is not also sterile
- effectiveness of both depends on faithful and conscientious practice by
those carrying them out

OPENING A STERILE PACKAGE AND PREPARING A STERILE FIELD

- sterile packages may be opened on a flat surface or while held in the
hands

1. POURING STERILE SOLUTIONS

- most solutions are considered sterile for 24 hours after they are
opened
- when pouring from a bottle, grasp the bottle so that the label is in the
palm of your hand
(prevents any liquid from running over the label and making it
illegible)
- if pouring from a bottle that has been previously used, “lip” it by
pouring a small amount out into a
waste receptacle to “clean” the rim of the bottle

2. ADDING STERILE SUPPLIES TO A STERILE FIELD

- sterile gloves are donned in a way that allows only the inside of the
gloves to come in contact with
the hands
- after gloves are on, only sterile items may be handled with the sterile-
gloved hands
3. POSITIONING A STERILE DRAPE
- sterile drape, which ideally is waterproof, may be used to extend the
sterile working area
- using sterile gloves allows the nurse to handle the entire drape surface
- for protection when positioning, fold the upper edges of the
drape over the sterile gloved
hands
- when sterile gloves are not worn, the nurse can touch only the
outer 1” of the drape
- use caution when shaking the drape open so as not to touch one’s
clothing or an unsterile object
- holding the drape by the 1” upper edge, position the drape over
the desired area
- do not reach over the drape

PREVENTING NOSOCOMIAL INFECTIONS

nosocomial – hospital acquired infection
- infection results while the patient is receiving healthcare and source is
either exogenous or
endogenous
- 5th leading cause of death in acute care settings

exogenous – causative organism is acquired from other people

endogenous – causative organism comes from microbial life harbored

in the person

iatrogenic – infection comes from treatment or diagnostic procedure

A. INVASIVE MEDICAL DEVICES

- urinary tract infections, pneumonia, and bloodstream infections are the
three most common
sources for nosocomial infections
- hemodynamic monitoring lines, hemodialysis equipment, and
respiratory equipment are
also examples
- patients receiving mechanical ventilation are especially at risk for
nosocomial pneumonia
- hands of the healthcare worker are the most significant means for
transmission
- surgical wounds are also a common site for infections to develop
- increasing use of biomedical equipment is often cited as a causative
factor

B. ANTIBIOTIC RESISTANT ORGANISMS

- indiscriminate use of broad-spectrum antibiotics has allowed once-
susceptible bacteria to develop
defenses against antibiotics
 - Methicillin Resistant Staphylococcus Aureus (MRSA), Vancomycin
Resistant Enterococcus (VRE),
Vancomycin Intermediate Resistant S. Aureus (VISA) are examples
- linezolid (Zyvox) is effective against the deadliest enterococcal
pathogens and provides an
alternative if vancomycin resistance develops
- administered IV or orally
- culture of a wound, blood, or other body fluids can identify the specific
organism present
- sensitivity test determines which antibiotic is most effective
against the organism

C. STRATEGIES TO PROTECT THE PATIENT

- MRSA and VRE are most often transmitted by the hands of the
healthcare providers
- can also be spread through patient contact with a contaminated
surface, such as side rails
or overbed table
- VRE lives much longer in the environment and is more likely to spread

Strategies instituting constant surveillance

having written infection-prevention practices for all
personnel
using practices to promote and keep patients in the best
possible physical condition
(meet nutritional needs, fluids, rest, oxygen, and
physical and psychological
comfort and security)

MEETING NEEDS OF PATIENTS REQUIRING INFECTION-CONTROL PRECAUTIONS

- sensory deprivation and loss of self-esteem may occur with patients
regarding the use of transmission-
based precautions
- emphasize: precautions are temporary
precautions and PPE protect the patient, caregiver, and other
patients
proper hand hygiene before and after visiting the patient
continued explanations about procedures and continued updates
on progress
- MUST document health teaching about barrier precautions in patient’s plan
of care

ACCIDENTAL EXPOSURE REPORTING

- nurses are accountable for their own safety
- any needlestick injury or accidental exposure to blood or body fluids
must be reported immediately
so that appropriate interventions can be used
 - failure to report may result in personal jeopardy as well as loss of
compensation if an infection
develops

Plan of Action: washing exposed area immediately

reporting incident to appropriate person and completing incident
report
reporting the source and nature of exposure
consenting to initial baseline blood test with follow up testing
consenting to postexposure prophylaxis
awaiting blood test results
attending counseling session regarding safe practices

TEACHING ABOUT INFECTION CONTROL

- patients need to be aware of techniques that prevent spread of infection
- medical asepsis techniques are appropriate for most procedures at home,
except self-injections and venous
catheter care

Home Practices: washing hands before preparing food and before eating
preparing foods at temps. high enough to ensure safe eating
using care with cutting boards and utensils – thorough
cleaning before and after
handling raw meat
keeping food refrigerated, especially those containing
mayonnaise
washing raw fruits and vegetables
using pasteurized milk and fruit juices
washing hands after using the restroom
using individual personal care items (washcloths, towels,
toothbrushes, etc.)

Public Practices: wash hands after using any public restroom

use paper towels or hot-air dryers in restrooms
use individually wrapped drinking straws
use tongs to lift food from common service trays

Community Practices: use sterilized combs and brushes in barber and beauty
shops
perform exam of food handlers for evidence of disease

CDC – Center for Disease Control

APIC – Association for Professionals in Infection Control and Epidemiology

OSHA – Occupational Safety and Health Administration

NIOSH – National Institute for Occupational Safety and Health

JCAHO – Joint Commission on Accreditation of Healthcare Organizations

HICPAC – Hospital Infection Control Practices Advisory Committee