17 - Aseptic techniques

Sterile gowning/gloving

Put on after the surgical scrub. Sterile surface is always required. Inside of sterile glove is considered nonsterile once it's touched. Cuff is foldered over to for a 2- to 3-inch cuff.

Surgical scrubbing purpose

To remove debris and transient microorganisms from the hands, nails and forearms; reduce resident microbial count to a minimum; and inhibit rapid rebound growth of microorganisms.

pneumothorax

accumulation of air or gas in the pleural space which may occur spontaneously or as a result of trauma or a pathologic process or which may be introduced deliberately

auscultation

act of listening for sounds within the body, chiefly for ascertaining the condition of the lungs, heart, pleura, abdomen, and other organs and for detecting pregnancy

Radiologic procedures that require aseptic techniques

angiography, arthrography, hysterosalpingography, and radiography in the surgical environment

Sterile corridor

area between the pt drape and the instrument table.

sterile

aseptic; free of living microorganisms

Pacemaker insertion - role of radiographer

assist physician in placement through fluoroscopy to ensure lead is in subclavian vein and advanced to the right atrium and end position is at the right ventricle.

dressing changes

best done in team setting. Secure privacy, explain procedure, and secure consent before begining.

self-gloving techniques

closed open

Suprapubic catheter

closed drainage system inserted approximately 1 inch above the symphysis pubis into the distended bladder. Performed under general anesthesia. Sutured to skin of abdomen. Reasons to use: long-term catheterization, urethral injury or obstruction, and following some gynecologic surgeries.

Besides radiographical procedures, what others require aseptic technique

dressing changes tracheostomies chest tubes catheterization intravenous/arterial lines pacemakers

Indications of normal breathing

duration pitch intensity of sounds

First task in providing care to tracheostomy pt

establish communication. Consists of yes/no questions, hand signals, and simple sign language. Don't use written methods because extremely ill pts have difficulty. Also be sensitive to unmet and inexpressible needs to keep anxiety level low. These pts need to have procedures explained and repeated.

Myelography pack

includes: Injectable local anesthetic syringes and needles of various sizes sterile drape collection tubes for spinal fluid

foley catheter

indwelling catheter retained in the bladder by a balloon inflated with air or fluid

urinary catheters

insertion of a tube into the bladder using aseptic technique. Can be used to: Empty the bladder (before surgery, radiologic or other exams, or childbirth) Relieve retention of urine or bypass obstruction Irrigate the bladder or introduce drugs Permit accurate measuring of urine output Relieve incontinence Can interrupt the body's defense mechanism against disease. Plastic ones are suitable for short-term use only. Latex ones can be used 2-3 weeks, and polyvinyl chloride for 4-6 weeks. Pure silicone ones are long-term, for 2-3 months. Urine bag should be kept low (below bladder level) to prevent reflux of urine back into the bladder. If not, it can lead to infection. Keeping it low also facilitates drainage by gravity. Should not drag on the floor. When using a wheelchair, ensure it and tubing do not get tangled in wheels or on passing objects. Most of the time, we do not catheterize pts. It depends on the setting.

who orders dressing changes and reapplication

the physician

Arterial lines include

the radial arterial and femoral arterial. Used for drawing blood and measuring blood pressure.

Intravenous and Intraarterial lines

Also called central venous lines. Intravenous lines are used for introduction of medications and measurement of central venous pressure. Swanz-Gans catheter is used to measure pumping ability of the heart and other heart parameters. Others include Intracath, Hickman, Broviac, and Arrow-Howest triple lumen.

Radiographer must use care when working with chest tube pt

Tubes can be pulled from body if caught by mobile unit or tugged roughly during handling of the pt or cassette. The exterior assembly of the chest tubes must always remain lower than the pt's chest. If pt is in dept. for longer period (over an hour), drainage of excess of 100 cc per hour should be reported, as well as any change from a serous fluid to a darker red color.

neonatal portable radiography

Two methods of gonadal shield are accepted: Contact - places lead directly on the infant's gonads. Greatest potential for cross-infection. Shadow - hangs a piece of lead in the beam or places a piece of lead on the isolette, casting a shadow in the collimator light. Requires low levels of ambient lighting for proper use.

Self-gloving

Using a closed or open gloving technique. After gowning or during sterile procedures that do not require donning a sterile gown. Jewelry must be removed first. Glove package should be opened facing the person with right glove on right side.

Emptying urine bag

When emptying it, output must be measured and recorded, unless otherwise noted. Reclamp the stopcock after the bag has been emptied. Record pt's intake of fluids, as well. Always check with nursing unit regarding recording intake and output.

Talking type of tracheostomy

allow for some speech

sterile packs

commonly used sterile packs include myelography, minor procedure, and various special procedure packs used for procedures such as venograms, angiograms and lymphangiograms.

first step in using a sterile drape

confirm that the package is sterile. Clean and dry, unopened and within expiration date. Otherwise it is not sterile.

purulent

consisting of or containing pus; associated with the formulation of or caused by pus

2 methods of neonatal gonadal shielding

contact shadow

Pacemakers

electromechanical devices inserted under the skin to regulate heart rate. Pt with bradycardia: most likely candidates for permanent pacemaker. It can prevent bradycardia by sensing the heartbeats of a pt and pacing the heart when it does not initiate a heartbeat on its own. 1 In wide in diameter and thickness, weighs just over 1 ounce. Has a pulse generator and circuitry and is connected to a lead. The tip of the lead contains a metal electrode that is put into contact with the heart. The electrode senses heartbeats and can also produce an electrical impulse to make the heart contract.

urinary meatus

external urethral orifice; the opening of the urethra on the body surface through which urine is discharged

Condom catheter

for males - condom with catheter at the end attached to a collecting bag. Allows an incontinent male the use of a catheter without the permanence or inconvenience of a foley or straight catheter. Susceptible to infection at the tip of the penis and requires regular cleaning, care and changing of the condom sleeve.

First priority for proper sterile technique

hand washing

Once container has been set down

it is no longer considered sterile and new container must be opened

atelectasis

lung collapse

Sterile field

microorganism-free area that can receive sterile supplies. Established using a sterile drape.

microorganisms

microscopic organisms; those of medical interest include bacteria, viruses, fungi and protozoa

Two methods of surgical scrubbing

numbered stroke method the timed scrub

Tracheostomies

operations performed under sterile technique that involves incising skin over trachea and making surgical wound in the trachea to provide airway during upper-airway obstruction. Used in emergencies and to replace airway provided by an endotracheal tube that has been in place for several weeks. To prevent skin breakdown, tracheostomies are always covered with a dressing.

lithotomy position

patient in the dorsal decubitus position with the hips and knees flexed and the thighs abducted and externally rotated; also called dorsosacral position. Used for female catheterization.

Trendelenburg position

patient is supine on table or bed, head of which is tilted downward 30-40 degrees and the table or bed in angled beneath the knees. Used for chest tube line placement.

Surgical asepsis

protection against infection before, during and after surgery by using sterile technique

MRI / pacemakers pt

pt may be scheduled for MRI - special care procedures are required. Shield pacemaker from the radiation field to keep from damaging the circuitry.

voiding cystourethrography

radiography of the bladder and urethra in which radiographs are performed before, during and after voiding. Often rad tech's job to remove a catheter after this procedure. Materials needed to remove an indwelling catheter are a basin (emesis basin), scissors, and several paper towels.

Catheter sizes

range from 8 to 18 in even numbers based on the French system. Indicates outer diameter of the catheter. Approximately 2.6 to 5.9 mm - choose a larger size when possible.

medical asepsis

removal or destruction of infected material but not 100%

serous

resembling serum, having a thin watery constitution

angiography

roentgenographic visualization of blood vessels following the introduction of contrast material; used as a diagnostic aid in conditions such as cerebrovascular attacks (strokes) and myocardial infarctions

arthrography

roentgenography of a joint after the injection of opaque contrast material

numbered stroke method

scrubbing a certain number of brush strokes for each finger, palm, back of the hand, and arm

Cross-infection importance

sepsis and nosocomial infections are recognized as major threats that results in morbidity and mortality each year in the neonatal unit. Maintaining asepsis is so important. Keep pieces of lead in the wards and sterilize after use, cover lead with pillow case or protective covering or assign a piece of lead to each crib and clean after each pt.

never tolerated

sloppy aseptic technique

Urinary catheter equipment

sterile catheter, sterile collecting bag, syringe with sterile water or saline catheterization kit: sterile gloves antiseptic solution sterile cotton balls and sterile forceps lubricant (water-soluble jelly) container to receive urine sterile drape for sterile field

Gloving another person

sterile person opens pkg and p/u the rt. glove and places palm away from himself. Slide fingers under the glove cuff and spread them making a wide opening. Keep thumbs under the cuff 2. the person thrusts his hand into glove. have a good grasp on the cuff is important 3. gently release cuff while roll it over wrist 4. Proceed with left glove using same tech.

tracheostomy

surgical creation of an opening into the trachea through the neck; also used to refer to the creation of an opening in the anterior trachea for insertion of a tube to relieve upper-airway obstruction and to facilitate ventilation

to minimize infection for trach pt

technologist should not touch a tracheostomy except under conditions of sterile technique. It must be suctioned often to remove secretions. Usually responsibility of resp. therapist, but may become our resp. Pt must be well aerated (5 to 10 breaths of O2) before suctioning - using an Ambu bag hooked to O2 source. Test patency of the suction catheter by aspirating normal saline through the catheter.

Establishing a sterile field

the drape is plucked with one hand by the corner and opened. Allow it to open freel without touching anything. Pick up another corner carefully and lay on a clean dry surface with bottom farthest from the person establishing the field.

Portable chest radiograph is used

to assess for pneumothorax. Gloves, masks, and gowns are typically worn. Patient is usually in Trendelenburg position when line is placed.

purpose of aseptic technique

to reduce the number of harmful microorganisms

Foley catheter

upon insertion, the balloon is filled with sterile water to hold the catheter in place. Also called an indwelling catheter.

Chest tubes

used to remove fluid, blood and air from the pleural cavity. Assist in reinflating collapsed lungs and alleviating pneumothorax and in cases of thoracotomy and open-heart surgery. Normally, the pleural cavity has no air or blood, but has a thin layer of lubricant to allow pleurae to slide and move over one another without friction.

temporary pacemakers

usually connected to a transvenous pacing electrode, and pacemaker is usually external to patient's body. Use same fluoroscopic technique to ensure proper insertion.

Minor procedure pack

(arthrography and biopsies) contains: Injectable local anesthetic syringes and needles of various sizes - 3 18-gauge, 1 20-gauge, 1 22-gauge, and 1 25-gauge (larger gauges are to inject local anesthtetic) sterile drape collection tubes sterile gown plastic connector for test injections of contrast material one maniforld scalpel handle and #10 scalpel blade for arterial cutdown techniques Lots of gauze pads or topper sponges up to five 10-, 20-, or 30-mL Luer-Lok syringes for saline flush 3 10-mL Luer-Lok syringes, 2 for contrast tests, 1 for local anesthetic forceps for sponges 6 sponges for prepping puncture site 3 stainless steel basins (for saline, antiseptic and waste basin.) may need another for emesis Straight and curved clamps for arterial cutdown techniques Clamp to keep guidewire wrapped Sterile screwdriver for tightening screws on manifolds

timed scrub

1. Be sure that scrub brushes, antiseptic soap, and nail cleaners are available 2. remove all jewelry, including watches 3. wash hands and arms with antiseptic soap 4. clean subungual areas with nail file 5. scrub sides of each finger, b/w fingers and back and front of hand for 2 minutes 6. scrub arm with hands higher than elbows - 3 inches - for 1 minutes 7. Repeat process for other hand and arm 8. Dry the hands from wrist to elbow. Do not allow towel to touch anything. Discard in linen hamper or kick bucket.

Dressing change procedure

1. Wash hands. Secure patient privacy, and obtain consent. Remove old adhesive tape around dressing. Baby oil may help with the pain involved. Limit the amount to avoid contaminating wound. 2. Remove dressing with forceps or gloved hands, wrapped and place in plastic bag. If it doesn't come off easily, appropriate person (nurse, supervisor, physician) should be contacted for additional instructions. 3. For reapplication, sterile technique is followed. Wash hands, Open sterile towel to use as a sterile field to place sterile dressings. Dressings are opened and placed on sterile towel. 4. Tape is cut into the lengths that will be needed. Do not place on sterile field 5. Gloves are donned and dressing is applieed. Remove gloves and secure dressing with tape. Wash hands again. Cover pt. and discard waste according to policy.

3 parts of the chest tubes

1. collection chamber - collects any fluid leaving the lung 2. water seal chamber - contains water and prevents air from entering cavity through the chest tube - drinking straw 3. Suction control chamber - contains water - amount of which regulates the amount of suction. Removes unwanted air or fluid from the pleural cavity. 4. Some have 4th chamber - water seal vented to the atmosphere to prevent potential pressure buildup.

Chest tube removal radiography examination

1. initial radiograph confirms full lung expansion 2. 2nd performed 2 hours after clamping to verify continued expansion 3. 3rd film is often obtained after removal to confirm full lung expansion

Procedure for suctioning

1. insert catheter in stoma without suction until pt coughs or until resistance is met. Withdraw the catheter approximately 1 cm before beginning suctioning. 2. Apply suction intermittently and withdraw the catheter in rotating motion. Activate suctioning by placing thumb over hole in suction line to cause suction to pull from end of tube where it placed in pt's body. 3. Assess airway by auscultation of the lungs. Breath sounds are result of free movement of air into and out of bronchial tree. Duration, pitch and intensity of sounds indicate whether breathing is normal or abnormal. 4. Repeat procedure until airway is clear. Never suction longer than 15 seconds. Allow pt to rest in b/w. Extra long tube may be used if distance b/w skin and trachea is too great (obese pts).

Gowning techniques

1. self gowning 2. gowning another person

Gloving techniques

1. self-gloving and 2. gloving another person

Self-gowning

12 inches from sterile area, p/u the gown by folded edges and lift it away from the package. Outside faces away. Step back from table, make sure no objects are near gown. Allow it to unfold gently. Do not shake. Place hands inside armholes and guide each arm through sleeves by raising and spreading arms 4. Unsterile asst. can adjust by standing behind and reaching inside the sleeves. 5. Pull sleeves over hands for open gloving technique of keep hands/fingers covered for the closed gloving technique 6. Asst. fastens the back and waistband of the gown. Only sleeves and front of gown to waist are considered sterile. People must pass back to back.

Closed technique - gloving

After donning gown, with fingers inside cuff of gown, pick up glove and lay it palm-down over the cuff of the gown. Fingers face you. Work through the gown sleeve to grasp the cuff and bring it over the open cuff of the sleeve unroll glove cuff so it covers the sleeve cuff 4. pull glove on by grasping the glove cuff and advancing the hand into the glove 5. proceed with opposite hand using same technique. Never allow bare hand to contact the cuff edge or outside of glove 6. fingers are adjusted until comfortable

Sterile procedures

Field includes patient, table and other furniture covered with sterile drapes and personnel wearing sterile attire

2 types of catheters

Foley catheter (retention balloon type) straight type catheter

Removing urinary catheter

Often rad tech's job to remove a catheter after this procedure. Materials needed to remove an indwelling catheter are a basin (emesis basin), scissors, and several paper towels. Procedure: 1. Wash hands, provide privacy, explain, get consent. 2. Uncover pt and place basin under catheter valve. Cut tip of balloon valve with scissors and allow water from balloon to drain. 3. When flow ceases, place paper towels under catheter and pull gently. Stop and notify phys/nurse if any resistance. 4. When completely removed, wrap it in paper towels, cover pt, and discard catheter.

Open technique - gloving

Pick up glove by its inside cuff with one hand. Do not touch outside of glove or wrapper. Slide glove onto the opposite bare hand leaving the cuff down with gloved hand, p/u the other glove by reaching under cuff. Touch only the outside surface of the glove with the gloved hand. Now sterile glove is pulled onto the hand without touching the inside surface

Opening a sterile drape

Place package on center of the surface with top flap to open away from person opening Pinch first flap on outside b/w thumb and index finger. Use right hand to open right flap and left to open left flap Grasp turned down corner, pull fourth flap. Inner surface of any of the package should not touch an unsterile object (a sleeve, e.g.) or entire package and contents are considered unsterile and must be replaced. Can also open using in the air with hands/wrist technique and drop contents onto sterile field from 6 inches above and at an angle.

C-arm

Requires increased attention to maintaining a sterile field. 3 approaches: 1. Most common - draping the image intensifier and C-arm with a "snap cover" - tension band is snapped in place when image intensifier and C-arm are covered with a sterile cloth or bags. Allows phys to manipulate the C-arm while maintaining a sterile field. 2. Hip pinnings or femur roddings may use the "shower curtain" approach. On affected side, a sterile clear plastic sheet is suspended from a metal bar attached to two vertical suspending rods. An opening is located in the middle, which is attached using special adhesive to the pt, allowing access to the surgical site. 3. Less common - drape the site with an additional sterile cloth. C-arm is brought over the area of interest. When no longer needed, it is removed, as is the cloth. This is a "stop-gap" measure and only useful when the physician does not need to manipulate the C-arm.

Portable and surgical radiography

Requires strict attention to the sterile technique. One constant is the existence of a sterile corridor. Cassettes are sometimes positioned under the table through a tunnel device; or enclosed in sterile covers and positioned by the physician. Sometimes in surgery, the machinery is left outside the roon until right before the procedure; or surgeon may want setup to occur before operation begins.

Dressing change equipment

Sterile disposable gloves Sterile Pack containing scissors, forceps, sterile towel, dressings, cotton-tipped swabs, and solution cup Sterile antiseptic solution and sterile saline Unsterile plastic bag for discarded dressings Unsterile properly sized adhesive Unsterile pads to protect surrounding area from secretions Gowns are recommended by many if the wound is purulent (containing pus). Treat all dressings as though they are infected. Do not touch with bare hands.

Pouring sterile solutions

Sterile on the inside but contaminated on the outside. Try to use the exact amount of solution. Solution is only sterile if it is used immediately. Always confirm the name of the solution and its strength by checking 3 times (show to another person, too) Procedure: 1. remove lid/cap, place it on an unsterile surface with topside down 2. hold bottle with label uppermost so that poured solution cannot stain and obscure label 3. Hold at height of 6 inches over bowl with as little of the bottom over the field 4. Don't splash. Can destroy a sterile field by allowing microorganisms to move from unsterile tabletop through the wet drape that forms the bottom of the sterile field.

Gowning another person.

Sterile person p/u gown by neckband, hold at arm's length and allow to unfold. 2. Gown is held by shoulder seams with outside facing sterile person. 3. Sterile gloves are protected by placing both hands under back panel of gown's shoulder 4. arms are slipped into the sleeves in a downard motion, sliding gown up to mid upper arms 5. nonsterile circulator pulls gown up and fastens back and waistband pull cuff back over person's hands being careful that your gloved hands do not touch the bare hands

Urinary catheterization procedure

wash hands, provide privacy, explain procedure, get consent. Place females in lithotomy position; males in supine and expose genitalia. Open kit and put on gloves place sterile drape around penis, or under buttocks of female If Foley, test-inflate the balloon by injecting a small amount of sterile water into the balloon port. If it holds, deflate it. If not, get another Foley catheter. Pour antiseptic over the cotton balls Coat the catheter tip with sterile lubricant Expose the urinary meatus using the nondominant hand. No longer sterile. With females, separate labia majora and minora. For males, hold penis with foreskin retracted. Clean meatus with cotton ball held by forceps. Twice. Insert catheter slowly with dominant hand until urine flows. .5 inch for females, 8 inches for males. Never force. Reattach syringe to balloon port and fill balloon. Lightly tug to ensure it's in place.