Aseptic Technique Wound Dressing
Asepsis can be defined as the complete absence of bacteria, fungi, viruses or other microorganisms that could cause disease. Aseptic techniques refer to a set of skills that are used to ensure any environment being examined or dressed remains free from micro-organisms by not directly touching the wound or any other surface that might come into contact with the wound (McFerran and Martin 2008). Sterilization techniques and effective hand washing technique also play a major role in maintaining aseptic conditions.
Aseptic techniques may be adopted in a number of environments including surgery, community and ward based nursing. There are many procedures which require asepsis such as inserting a catheter, suturing a wound (Aziz 2009) or inserting a vascular access device (NICE 2013). I will be looking at the use of aseptic techniques when dressing a wound in particular. Wounds can be divided into two categories, surgical and traumatic. Surgical wounds are produced and closed under controlled conditions intended to prevent the access of microbes, healing by primary intention.
Traumatic wounds may be heavily contaminated with microorganisms and are left open to cleanse and heal by secondary intention (Ayliffe et al 1999). Wound dressings are carried out frequently on wards and in the community and can involve leg ulcers, pressure sores and less superficial wounds healing by primary intention. Wounds healing by secondary intention are left open to allow the free drainage of exudate and the formation of granulation tissue to fill the cavity (3M 2013). I will explain the importance of the techniques used, when it is required for them to be used and why it is relevant to contemporary nursing practice.
I will discuss the risks associated with the techniques, how they should be performed with a range of opinions from evidence based practice including the rationale behind the technique. The aseptic ‘non-touch’ technique (ANTT) is based upon theoretical framework and best available evidence (ANTT 2011). It is adopted when attending to wounds which require aseptic conditions. The procedure is comprised of four points which focus around timing, equipment, the patient and the technique (Aziz 2009). Rowley (2010) describes aseptic non-touch technique as a method of changing a dressing without directly touching the wound.
Ayliffe et al (2000) concludes; by ensuring that only sterile fluids or uncontaminated objects make contact with the wound, an aseptic field can be maintained by preventing the contamination of susceptible sites. Firstly the nurse must make the decision about which technique to adopt, this may be dependent on a number of factors. The location the procedure is being performed in may influence the nurse to choose one technique over the other. District and community nurses may choose the clean technique as it is believed that it is not always possible to achieve a completely aseptic field in a patients home.
The longevity of the wound will also contribute to the decision to use the clean or aseptic technique. Chronic wounds may be treated as infected and therefore a clean procedure will be used however an acute short-term wound may be treated aseptically (Flores 2008). According to Aziz (2009) the technique is comprised of effective hand washing, maintaining an aseptic field and glove choice. A clean, flat surface is required to place sterile equipment on, this should be a dressing trolley on a ward. In a patients home it may be a chair, table or even the floor.
A ‘wound dressing’ kit is made up by the nurse and should have a sterile dressing pack, the appropriate dressing, bandages, scissors, hypo-allergenic tape and syringes for irrigation. It should also contain personal protective equipment (PPE), including gloves, an apron and also alcohol hand rub. A solution for cleaning or irrigation which may consist of sodium chloride (normal saline), sterile water or an antiseptic solution should be included depending on the type of wound and method chosen for cleansing (Pegram and Bloomfield 2010).
The procedure involves creating a sterile environment, removing the old dressing or cleansing the wound and area surrounding it. Depending on the type of wound this may include debridement, swabbing or using fluids to remove debris and necrotic tissue. Some patients may even prefer to shower their wounds with tap water. This should be discussed with the nurse as a preferred and more suitable method for irrigation, as swabbing may damage fragile granulation tissue (Briggs 2008) as cited by Griffiths et al (2001).
Once the wound has been cleansed a new dressing appropriate for the type of wound should be applied as quickly as possible to minimise airborne contamination (Pegram and Bloomfield 2010). All equipment used in the procedure should be put in the waste bag provided and disposed of in an appropriate bin. The ANTT may be used by nurses when they are cleansing wounds or changing dressings. Wounds healing by primary or secondary intention should be approached in the same manner whether the wound is open or closed ensuring asepsis throughout.
A solution that is non-toxic to the tissue is used to remove debris, wound exudates and metabolic wastes, these processes are used to cleanse the wound and help to promote wound healing (Briggs 2008). The ANTT should be adopted when attending to surgical site wounds, pressure ulcers, diabetic foot ulcers, leg ulcers and less superficial wounds such as skin tears and scrapes where the integrity of the skin has been breached or compromised and no longer provides an effective barrier to microorganisms.
Aseptic technique skills are relevant to contemporary nursing practice as they limit the spread of contamination from infected wounds to other parts of the body or to healthcare staff. Methods such as debridement and cleansing with tap water or normal saline help to remove metabolic wastes, slough and dead skin cells. However Briggs (2008) explains that there is no research to support or refute swabbing or scrubbing wounds to cleanse them.
Applying the correct dressing such as an interactive dressing promotes the wound healing process by creating and maintaining a moist, warm environment ideal for the growth of microorganisms (NICE 2013). This environment is also favourable to microorganisms which are pathogenic, which is why maintaining an aseptic field is vital to prevent contamination of a patients wound. In order to stay relevant the original ANTT guidelines have changed slightly in keeping with a reduction in healthcare costs and time spent on individual patient care.
Forceps were once used to remove dressings however this required sterilization of equipment prolonging the procedure. The modern day technique encourages using the hand placed in the sterile waste bag to remove dressings, this reduces the time taken performing the technique and the need for unnecessary cleaning of equipment. A breach in skin integrity such as a wound reduces the skins protective mechanisms, due to a reduction in the body’s defences the patient is more vulnerable to acquiring a healthcare associated infection (HAI) (PRACTICE NURSE 2003).
The (hand in hand 2008) DVD recorded that 9% of the UK population have suffered from a HAI. HAIs account for more than 5000 deaths annually at a cost of ? 1 billion to the NHS (AZIZ 2009). Due to the increasing risk factors patient safety should be of the highest importance when performing the aseptic technique (Preston 2005). Aziz (2009) has a similar opinion in that all healthcare workers should exercise universal infection control precautions whether the risk is known or unknown in order to protect themselves and their patients from the transmission of infection.
Before, throughout and after the procedure has been performed risks should be taken into account and the appropriate tools to recognise, monitor and manage a risk should be used (Flores 2007). Hand hygiene, aseptic techniques and use of PPE are risk elements identified by the DoH (2006). The necessary education, training and assessment should be provided to all healthcare workers performing the procedure, so that their technique is kept up to date and relevant. (Unsworth 2011).
In addition audits and review tools could be used to monitor and improve the quality of infection prevention and control when performing aseptic techniques. Nurses’ are required to keep their knowledge and skills up to date (NMC 2008) and should adhere to risk assessment protocols, including audits and attending updates on developments in healthcare practice (Preston 2005). By completing these checks the nurse is aiming to eliminate the risk of infection in the procedure. It is difficult for nurses in practice to perceive the relationship between contamination, colonization and infection (Preston 2005) when the threat cannot be seen.
(Meers et al 2001) conclude that it is not known at which point open wounds, which have been colonized by the patients own microbial flora become infected. This reiterates the need for aseptic conditions as wounds have the potential to be infected by multi-resistant hospital strains of bacteria (Meers et al 2001). Health and safety risks can be limited by getting to know your patient. The success of the procedure may depend on the cooperation of the patient, this may prove difficult if the patient lacks mental capacity or has a learning disability.
Depending on the environment, type and location of the wound it is the nurse’s responsibility in deciding which technique to use. In some community settings such as a client’s home it may only be possible to achieve a clean field rather than an aseptic field. Hallett (2009) has shown this is often the case, in his research nurses have highlighted the difficulties of maintaining control over an aseptic procedure due to the unpredictable nature of the environment. The technique is reliant on the nurse carrying out effective hand washing before, after and each time they believe their hands to be contaminated.
The World Health Organisation recommend using the ‘5 moments for hand hygiene’ approach when providing patient care. This involves washing the hands before patient contact, before an aseptic task and after body fluid exposure. Hands must be cleaned each time after touching a patient or any items in their immediate surroundings (WHO 2009). This approach may not always be possible in community settings and in this instance alcohol hand rubs should be used. Personal protective equipment must be worn in the form of disposable gloves and an apron.
The dressing can be removed by placing the hand inside the waste bag which comes in the sterile pack. Some guides will recommend washing the hands again however there is no research evidence to support this. Alcohol hand gel should be used at this point before donning sterile gloves, assessing, cleansing and dressing the wound. PPE should then be removed and discarded along with the sterile dressing pack followed by washing the hands (Preston 2009). Before starting the procedure it is important to gain consent from the client and ensure they understand what is going to happen.
It is the nurse’s responsibility to minimise pain and promote the general wellbeing of people in their care (NMC 2008). Through communicating with the patient the nurse can ascertain whether any pain relief will be required. This is an important factor as having a painful wound can be disabling and interfere with self-care, sleep and can cause anxiety and depression (Benbow 2009). Throughout the procedure it is also important to inform the patient and involve them in the process, this can help to alleviate any anxiety (Pegram and Bloomfield 2010).
In some situations there may be barriers to providing the best possible care, for example a client may have a learning disability, mental health problem or cognitive impairment. Age and gender may be an issue when attending to patients’ wounds. For example a female patient may not wish for a male nurse to attend to a wound that is situated in a sensitive location that may be embarrassing to them. It is always important to consider actions that may compromise a patient’s dignity and to respect their choices. Younger clients including children and infants may not understand the procedure and therefore are uncooperative.
It is imperative the nurse has the permission and cooperation of the parent or guardian. There may be a language barrier if English is not the patient’s first language, in this case it is the nurses responsibility to act in the best interest of the patient. This may mean using an interpreter or asking a family member or friend who speaks English to translate for the nurse so that the patient understands and is comfortable with the procedure.
In extreme circumstances a patient may have an adverse reaction or sensitivityto part of the equipment required for the technique such as the gloves, saline or type of dressing. It is helpful to be aware of this, check patients past medical history and use alternative products which have been authorized by infection prevention and control. Furthermore when adhering to patients with mental health problems it is sensible to have another responsible adult present who recognises their needs. A third party such as a carer, nurse or family member will be able to account for the nurses actions and provide evidence that they attempted to provide the best possible care for that patient.
Legislation is vital in the nursing profession, the correct documentation will protect the nurse if there are any problems and hold the correct person responsible, providing it is completed correctly. On a ward a patient will have a wound care plan in which the nurses’ will document the type of care they have provided and the type of dressing they have applied, it is a similar format in the community. This ensures that there is a record of what care has been given, why and who performed it. In addition location, size and depth may prove difficult when dressing a wound.
For example a client with a pressure sore on their sacrum will need to be on their side for most of the procedure, this may require another nurse or healthcare worker depending on the cognitive ability, cooperation and mental capacity of the patient. The Aseptic technique is relevant to contemporary nursing practice as it provides a framework for maintaining an aseptic field when attending to wound care. It aims to protect patients and other healthcare workers from healthcare associated infections and to prevent the transmission of microorganisms to wounds (Preston 2005).
(Aziz 2009) argues the technique needs to be given a higher priority as we cannot physically see the problem and some nurses become complacent with infection control due to this fact (Preston 2005). Despite the ANTT being implemented across NHS trusts to standardize the procedure, there is still little evidence to suggest that the aseptic technique is more beneficial than the clean technique (Aziz 2009). With regards to hand washing it is widely recommended that hands must be decontaminated before and after direct contact with a patient which could result in the hands becoming contaminated (Pratt et al 2007).
However this does not always occur as it should. Hanna et al (2009) established that compliance with hand washing guidelines decreased as workload and stress increased. Hanna et al (2009) and Aziz (2009) agree that the healthcare workers perception of risk of infection and their own susceptibility play a part in adhering to effective and regular hand washing. The use of sterile or non-sterile gloves are part of standard universal precautions and hands should be washed before and after donning gloves as they cannot always provide complete protection against hand decontamination (Flores 2007).
In conclusion the aseptic technique is relevant and beneficial to contemporary nursing practice however in some circumstances it may not always be possible to achieve an aseptic environment and in this case the ‘clean’ technique should be adopted. It is widely agreed that the aseptic technique has become incorporated into nursing ritual and is often based more on tradition than on rational reason or research evidence (Wilson 2006).
With regards to wound care the clean technique could be adopted in many circumstances, particularly with chronic wounds such as leg ulcers (Unsworth 2011). The only difference between the two procedures is the use of clean rather than sterile gloves. In my opinion there is much uncertainty about when exactly the aseptic technique should be used. There needs to be more research from evidence based practice to support the procedure especially in community settings, due to the increase in developing out-of hospital care based in patients’ homes (Unsworth 2011).