Clinical Nursing Skills CH 8, 18, 38, 39, and 40

The absence of disease-producing (pathogenic) organisms

latex allergy reaction
Allergic response to products containing latex (e.g., gloves, medical devices). Can present as contact dermatitis, allergic rhinitis, or immediate life-threatening reactions leading to such conditions as urticaria, bronchospasm, and edema. (Perry 1162)

Any microscopic entity capable of sustaining living processes such as bacteria, virus, or fungi, only some of which typically cause human disease. (Perry 1162)

Pathoggenic microorganisms
Those capable of producing an infection or disease

Standard precautions
Techniques used to reduce the risk for the transmission of bloodborne pathogens or microorganisms present in moist body substances regardless of a patient’s diagnosis or infection status. (Perry 1166)

Free from all life forms, including spores

Sterile Field
a specified area, such as within a tray or a sterile drape, that is considered free from microorganisims

Strike through
source of contamination by which moisture permeates a sterile field or barrier

Surgical asepsis
Practice or techniques designed to render and maintain objects areas free from pathogenic microorganisms. Also referred to as sterile techniques

Transmission -based precautions
Techniques used to prevent the transmission of microorganisms from patients documented or suspected to be infected with highly transmissible pathogens for which additional precautions beyond standard precautions are needed. The three types are airborne, droplet, and contact precautions (Perry 1167)

Box 8-1 Principles of Surgical Asepsis
1 All items used within a sterile field must be sterile.

2 A sterile barrier that has been permeated by punctures, tears, or moisture must be considered contaminated.

3 Once a sterile package is opened, a 2.5-cm (1-inch) border around the edges is considered unsterile.

4 Tables draped as part of a sterile field are considered sterile only at table level.

5 If there is any question or doubt about the sterility of an item, the item is considered to be unsterile.

6 Sterile persons or items contact only sterile areas; unsterile persons or items contact only unsterile areas.

7 Movement around and in the sterile field must not compromise or contaminate the sterile field.

8 A sterile object or field out of the range of vision or an object held below a person’s waist is contaminated.

9 A sterile object or field becomes contaminated by prolonged exposure to air; stay organized and complete any procedure as soon as possible. (Perry 182)

Primary situations why nurse would use aseptic techniques at patient’s bedside
During procedures that require intentional perforation of a patient’s skin (e.g., insertion of central intravenous [IV] catheters [see Chapter 28])

• When the integrity of the skin is broken because of a surgical incision or burns (see Chapters 38 and 39)

• During procedures that involve insertion of devices or surgical instruments into normally sterile body cavities (e.g., insertion of a urinary catheter [see Chapter 33]) (Perry 181)

Nurse in OR vs. nurse at patient’s bedside or home setting
A nurse in an OR follows a series of steps to maintain sterile technique, including applying a mask, protective eyewear, and a cap; performing a surgical hand scrub; applying a sterile gown; and applying sterile gloves. In contrast, a nurse performing a sterile dressing change at a patient’s bedside or in the home setting may only wash his or her hands and apply sterile gloves. (Perry 181)

Joseph Lister
1860 promoted carbolic acid as surgical hand scrub

Increase of risk of infection
invasive procedures such as IV line or urinary catheter pose a risk for infection

Safety Guidelines
Follow standard precautions with all patients.

2 Review agency policies and procedures before conducting a sterile procedure.

3 Assess a patient’s potential for infection before choosing the barrier to be used such as masks or protective eyewear.

4 Use barrier techniques to decrease the transmission of microorganisms from health care personnel and the environment to a patient.

5 Remain organized while performing any sterile procedure; keep bedside surfaces clutter free.

6 Remember that hand hygiene is essential before initiating any sterile procedure.

7 Incorporate the principles of surgical asepsis when conducting any sterile procedure. (Perry 182-183)

Step Rationale Assessment
1 Review type of sterile procedure to be performed and consult agency policy for use of mask/caps/protective eyewear.

Not all sterile procedures require mask, cap, or protective eyewear. Ensures that nurse and patient are properly protected.

2 If you have symptoms of a respiratory infection, either avoid participating in procedure or apply a mask.

A greater number of pathogenic microorganisms reside within the respiratory tract when infection is present.

3 Assess patient’s actual or potential risk for infection when choosing barriers for surgical asepsis (e.g., older adult, neonate, or immunocompromised patient).

Some patients are at a greater risk for acquiring an infection; thus use additional barriers.


• Ineffective protection

• Risk for infection

Related factors are individualized based on patient’s condition or needs.


1 Expected outcome following completion of procedure:

• Patient does not develop signs of localized infection (e.g., redness, tenderness, edema, drainage) or systemic infection (e.g., fever, change in white blood cell [WBC] count) 24 hours after procedure.

Indicates lack of microorganism transfer to patient and sterile field.

2 Prepare equipment and inspect packaging for integrity and exposure to sterilization.

Ensures availability of equipment and sterility of supplies before procedure begins.


1 Perform hand hygiene

Reduces transient microorganisms on skin.

2 Apply a cap.

a If hair is long, comb back behind ears and secure.

Cap must cover all hair entirely.

b Secure hair in place with pins.

Ensures that long hair does not fall down or cause cap to slip and expose hair.

c Apply cap over head as you would apply hairnet. Be sure that all hair fits under edges of cap (see illustration).

Loose hair hanging over sterile field or falling dander contaminates objects on sterile field.

STEP 2c Apply cap over head, covering all hair.

3 Apply a mask.

a Find top edge of mask, which usually has thin metal strip along edge.

Pliable metal fits snugly against bridge of nose.

b Hold mask by top two strings or loops, keeping top edge above bridge of nose.

Prevents contact of hands with clean facial portion of mask. Mask covers all of nose.

c Tie two top strings at top of back of head, over cap (if worn), with strings above ears (see illustration). Alternatively place loops over ears.

Position of ties at top of head provides tight fit. Strings over ears may cause irritation.

STEP 3c Tie top strings of mask.

d Tie two lower ties snugly around neck with mask well under chin (see illustration).

Prevents escape of microorganisms through sides of mask as you talk and breathe.

STEP 3d Tie bottom strings of mask.

e Gently pinch upper metal band around bridge of nose.

Prevents microorganisms from escaping around nose and eyeglasses from steaming up.

4 Apply protective eyewear.

a Apply protective glasses, goggles, or face shield comfortably over eyes and check that vision is clear (see illustration).

Positioning affects clarity of vision.

STEP 4a Apply face shield over cap.

b Be sure that face shield fits snugly around forehead and face.

Ensures that eyes are fully protected.

5 Apply sterile gloves if needed (see Skill 8-3).

6 Remove protective barriers.

a Remove gloves first if worn (see Skill 8-3).

Prevents contamination of hair, neck, and facial area.

b Untie bottom strings of mask.

Prevents top part of mask from falling down over uniform. If mask falls and touches uniform, uniform will be contaminated.

c Untie top strings of mask and remove mask from face, holding ties securely. Discard mask in proper receptacle (see illustrations).

Avoids contact of nurse’s hands with contaminated mask.

STEP 6c A, Untie top mask strings. B, Remove mask from face. C, Discard mask.

d Remove eyewear, avoiding placing hands over soiled lens.

Prevents transmission of microorganisms.

If wearing face shield, remove it before removal of mask. NOTE: A combination mask and eyewear is available in some agencies.

e Grasp outer surface of cap and lift from hair.

Minimizes contact of hands with hair.

f Discard cap in proper receptacle and perform hand hygiene.

Reduces transmission of infection.


1 Following the procedure, assess area of body treated for drainage, tenderness, edema, or change in temperature or color of skin.

Rules out presence of localized infection.

Unexpected Outcomes

Related Interventions

1 Redness, heat, edema, pain, or purulent drainage develops at wound or treatment site, indicating possible infection.

• Notify health care provider of change in condition of affected area and initiate appropriate treatments as ordered. (Perry 183-185)

Perry, Anne, Patricia Potter, Wendy Ostendorf. Clinical Nursing Skills & Techniques, 8th Edition. Mosby, 2014. VitalBook file.

The citation provided is a guideline. Please check each citation for accuracy before use.

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