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Clinical Nursing Skills

6.2 Asepsis and PPE

Clinical Nursing Skills6.2 Asepsis and PPE

Learning Objectives

By the end of this section, you will be able to:

  • Define the two types of asepsis
  • Recognize the negative implications healthcare-associated infections have on healing
  • Correlate appropriate personal protective equipment with their necessary uses

Nurses in all roles are in a unique position to create a safe patient care environment. From bedside nurses to executives, fostering safe healthcare environments can prevent the transfer of pathogens and the spread of infection. With evidence-based practices, nurses can facilitate a patient’s plan of care and recovery while minimizing risks and complications related to infections. Proper use of infection-control measures can directly affect patient morbidity and mortality.

Asepsis

The state of being free from disease-causing contaminant is referred to as asepsis. These contaminants include bacteria, viruses, fungi, and parasites. The term asepsis can also refer to the process of preventing infection by minimizing the number of contaminants present and decreasing the ability to transport pathogens. The two types of asepsis include medical and surgical (Table 6.3). Furthermore, medical asepsis has three degrees: sanitization, antisepsis, and disinfection. An example of sanitization is physically removing microorganisms by cleaning linen. An example of antisepsis would be preoperative skin cleansing. Disinfection kills microorganisms on objects such as tables or blood pressure cuffs that come into contact with the patient or patients. This process utilizes strong chemicals called disinfectants, which should not be used on skin.

Medical Asepsis Surgical Asepsis
Referred to as “clean technique” Referred to as “sterile technique”
Reduces number of pathogens Eliminates all pathogens
Used in administering:
  • Medications
  • Enemas
  • Tube feedings
  • Daily hygiene
Used when performing:
  • Dressing changes
  • Catheterizations
  • Surgical procedures
Table 6.3 Types of Asepsis

Medical Asepsis

The techniques and procedures used to decrease the potential for the spread of microorganisms and infection is called medical asepsis. Medical asepsis is also referred to as “clean technique” in the healthcare environment because it is a standard practice used to avoid spreading infection from one person to another throughout a facility. The core practices of medical asepsis include hand hygiene, environmental cleanliness, and the use of protective equipment and isolation.

Surgical Asepsis

The absence of all microorganisms within any type of invasive procedure is called surgical asepsis. Maintaining surgical asepsis requires the use of sterile technique, a set of specific practices and procedures that are performed to make an environment and equipment in that environment free of all microorganisms. Principles of sterile technique help control and prevent infection. Sterile technique is discussed in depth in 6.3 Sterile Technique.

Hand Hygiene

The term hand hygiene refers to the act of handwashing, hand rubbing (using alcohol-based hand sanitizer), or surgical hand antisepsis. Hand hygiene is regarded as one of the most important elements in the prevention and control of infections. Hand hygiene that is timely and effective protects patients, healthcare workers, and the healthcare environment from the spread of infection. Hand hygiene should be performed when arriving and leaving a patient care unit, before direct contact with a patient, before and after removing gloves, after contact with patient’s skin, and when hands are visibly dirty or soiled with blood or bodily fluids. Healthcare providers may be required to wash their hands as many as 100 times in a twelve-hour shift, depending on the number and acuity of patients.

Cleaning hands using an alcohol-based sanitizer is an effective form of hand hygiene if the hands are not visibly soiled. The advantages of alcohol-based hand hygiene are that it takes only twenty to thirty seconds, can be completed directly at the point of care, and does not require a sink, water, or towel. Alcohol-based hand sanitizers can kill most pathogens. Keep in mind, however, that certain bacteria are not removed by hand sanitizers. These bacteria are only removed by handwashing. One example of bacteria that is only removed with soap and water is Clostridioides difficile (C. diff). Nurses who take care of patients with C. diff or other stubborn bacteria will usually be told before they commence care. When these instances occur, the nurse will know to avoid the hand sanitizer and choose to wash their hands with soap and water instead. When in doubt, washing your hands is the best choice.

Washing hands with soap and water is recommended if the hands are visibly dirty, soiled, or are contaminated with blood or other bodily fluids. It is essential to spend the proper amount of time on handwashing; washing hands for at least thirty seconds removes up to ten times the number of bacteria as does washing for fifteen seconds.

Patient Conversations

Understanding When to Use Soap and Water for Hand Hygiene

Scenario: The nurse is entering a patient’s room to complete q4h vital signs. This patient is currently positive for Clostridioides difficile. After donning personal protective equipment, the nurse enters the room.

Nurse: Hi, Ms. Lee, it’s your nurse Bryan. I’m here to get your vital signs. Let me wash my hands, and we will get started. How are you feeling?

Patient: I’m doing okay, I suppose. I’m not in any pain right now, so that’s good news.

Nurse: That’s excellent. Let me just put on a pair of gloves, so I can verify your name on your wristband. Can you tell me your name, date of birth, and if you have any allergies?

Patient: Yang Lee, 03/27/1942. I’m allergic to iodine. Why did you wash your hands when you came in here when there’s hand sanitizer over by the door?

Nurse: Performing proper hand hygiene is a critical component of preventing the spread of infections, especially in the hospital. Alcohol-based hand sanitizers are a great method for cleaning your hands, but there are times when it is not effective.

Patient: Is getting my vital signs one of those times?

Nurse: The stool sample that was sent to the lab on Monday came back positive for a bacteria called Clostridioides difficile, or C. diff. Alcohol alone cannot kill C. diff spores, and studies have shown soap and water to be much more effective at removing them. In order to prevent the spread of infection, you’ll notice that all of the healthcare workers will be washing their hands with soap and water when they enter and exit your room.

Patient: So, should I wash my hands too?

Nurse: Since you already have C. diff, you cannot infect or re-infect yourself. However, washing your hands will prevent you from getting bacteria such as C. diff in the future. Additionally, washing your hands will help prevent spread to others inside and outside of the hospital. Nurses always wash our hands frequently because it washes away all kinds of bacteria. It really is the best way to prevent spreading bacteria.

Patient: That makes sense. I wouldn’t want anyone else to get sick from what I have. Thank you for being so careful.

Healthcare-Associated Infections

Healthcare-associated infections (HAIs), also known as nosocomial infections, are infections acquired while receiving medical treatment in a healthcare facility. Although preventable, HAIs are some of the most common complications for patients within a healthcare setting and can prolong hospital stays and recovery time. According to the CDC, one in every twnty-five hospitalized patients will contract an HAI (CDC, 2022). The most common HAIs are associated with invasive devices such as catheter-associated urinary tract infections (CAUTIs), central line–associated bloodstream infections (CLABSIs), ventilator-associated pneumonia (VAP), and surgical site infections (SSIs).

The risk for developing an HAI is dependent on the infection-control policies within a facility and the degree of adherence to them. Additional risk factors include a patient’s immune status, age, underlying comorbidities, and the prevalence of pathogens within the environment. Length of hospitalization, number of invasive procedures, and amount of antibiotic therapy received all increase a patient’s risk for acquiring an HAI.

Preventing Healthcare-Associated Infections

Nurses are at the front line for preventing the transmission of pathogens through infection-control policies and procedures. These evidence-based prevention strategies and control practices can directly reduce HAIs. Appropriate hand hygiene and glove usage heavily contributes to an increase in patient safety and the prevention of HAIs. Keeping a healthcare environment clean by disinfecting equipment between patients is an additional vital prevention measure. Additionally, the use of proper personal protective equipment can prevent the transmission of pathogens. Nurses must stay current with how to protect themselves from newly identified pathogens and adhere to the protocols put in place. In recent history, viruses such as Ebola and the coronavirus that caused the COVID-19 pandemic all required specific infection-control measures. Healthcare providers were and still are on the front lines in these instances and must also educate the public and their patients about necessary protocols.

Clinical Safety and Procedures (QSEN)

QSEN Competency: Safety: Preventing HAIs

Definition: Quality and Safety Education for Nurses (QSEN) competencies were designed to emphasize key elements that pre-licensure nursing students should be competent in at the time of graduation. Safety is defined as minimizing risk of harm to patients through both systems effectiveness and individual performance.

Knowledge: Students will examine human factors and other basic safety design principles as well as commonly used unsafe practices, using evidence-based sources to enhance knowledge.

Skills: Students will demonstrate effective use of strategies to reduce risk of harm to self or others.

Attitudes: Students will value their own role in preventing errors and reducing the spread of infections.

Clinical scenario: A new nurse is working on a medical-surgical unit. Bedside shift report is beginning, and the nurse notices a sign on one patient’s door stating that the patient is on airborne precautions. The box of masks located outside the patient’s room is empty.

Step 1: The nurse uses knowledge to recognize that the patient’s condition warrants airborne precautions and that masks are the first line of defense for reducing the spread of airborne pathogens. The nurse uses knowledge of evidence-based sources to confirm that entering the room without a mask would place themselves and other patients on the unit at risk for exposure to the identified pathogen.

Step 2: The nurse identifies the skill of replacing the empty box before anyone can enter the room as an effective use of infection-control strategies to reduce risk of harm to self or others.

Step 3: The nurse stops and replaces the supplies outside the patient’s room before continuing with the morning report. The nurse can now begin the shift with a positive attitude, knowing value is placed on their role in reducing the spread of infection and providing quality, competent nursing care.

Reporting Healthcare-Associated Infections

As part of its mission in healthcare safety, the CDC has developed the National Healthcare Safety Network (NHSN), the nation’s most widely used system for tracking and surveillance of HAIs (CDC, 2022). More than 38,000 healthcare facilities provide data to the NHSN, which are, in turn, used for analysis and development of prevention initiatives by states, regions, and national public health agencies. These agencies include acute care/critical access hospitals, long-term care facilities, ambulatory surgery centers, long-term acute care facilities, inpatient psychiatric facilities, inpatient rehabilitation facilities, and dialysis facilities. The report provides data on CLABSIs, CAUTIs, ventilator-associated events (VAEs), SSIs, methicillin-resistant Staphylococcus aureus (MRSA) bloodstream events, and C. diff events. Federal government bodies such as the Centers for Medicare and Medicaid Services (CMS) use these data to determine performance incentives. Community members can use this information to select the healthcare facilities that they feel best fits their needs.

Personal Protective Equipment

Healthcare workers use personal protective equipment (PPE) as a means of barrier protection for their eyes, nose, mouth, and skin from exposure to blood and other potentially infectious bodily fluids and materials. The most commonly worn PPE includes gloves, gowns, face masks, protective eyewear, and face shields. These barriers are used in both standard precautions as well as in transmission-based precautions. Every nurse must be knowledgeable about the appropriate PPE to wear in various situations. Simply wearing all available PPE is not appropriate practice and is wasteful considering healthcare resources.

Clinical Judgment Measurement Model

Take Action: Initiating the Use of Additional Personal Protective Equipment

This scenario requires a nurse to take action to prevent infection from spreading. A nurse is reviewing a patient’s morning laboratory results. The nurse notes that the patient’s stool culture has come back positive for vancomycin-resistant Enterococci (VRE). Knowing the method of transmission of VRE (contaminated equipment, surfaces, hands), the nurse analyzes these data and prioritizes how they will be incorporated into the patient’s care. The nurse knows that additional interventions will need to be implemented.

The nurse hangs a contact isolation sign on the door and places a PPE cart next to the room. The cart contains masks, gloves, face shields, hand sanitizer, and disinfectants, among other PPE items. When the nurse enters the patient’s room, they don the appropriate PPE per facility policy. They also provide the patient with education regarding why they will be seeing staff wearing additional PPE.

Gloves

The use of gloves in the healthcare setting prevents contamination of the hands and reduces the likelihood of the transmission of pathogens (Figure 6.5). Medical gloves should be worn when providing care to protect the healthcare provider as well as the patient. Further, sterile gloves should be worn for procedures that pose greater risk of contamination to the patient, which are indicated as sterile procedures. Gloves are only effective in infection prevention if they are used properly, and the wearer performs proper hand hygiene before and after wear. Gloves should be removed and hand hygiene should occur once contact with blood or bodily fluids has ended, once contact with a single patient has ended, when leaving a patient’s room, and when there is a need for hand hygiene. The same pair of gloves should never be worn more than once.

A photograph shows a healthcare worker putting on gloves.
Figure 6.5 Donning nonsterile gloves in a healthcare setting is one of the most effective ways to prevent infection. (credit: “13550,” by Amanda Mills/Centers for Disease Control and Prevention, Public Domain)

Gowns

A medical isolation gown is a long-sleeved garment that covers the body front and back from the neck to the thighs, overlaps or meets in the back, fastens at the neck and waist, and is easy to put on and take off. They are used in the healthcare setting as a broad barrier against blood or bodily fluids. Gowns are used for patients who are on contact and droplet precautions and for any potentially splash-generating procedures. Medical isolation gowns must be removed before leaving an individual patient area and hand hygiene must occur. A surgical gown is worn by healthcare personnel during a surgical procedure to protect both the patient and the personnel from transmission of pathogens. Examples of gowns can be seen in Figure 6.6.

Image (a) shows a healthcare worker wearing a blue medical gown, while image (b) shows a healthcare worker wearing a blue surgical isolation gown.
Figure 6.6 Multiple styles of gowns may be available within a healthcare setting. (a) Medical and (b) surgical isolation gowns can be worn with additional forms of PPE such as masks, gloves, goggles, and shoe covers. (credit a: "Call to Service: Army psychologist on the COVID-19 battlefront" by unknown, Public Domain; credit b: "USMC-080618-M-0884D-002.jpg" by Sgt. Rocco DeFilippis, Public Domain)

Masks

Healthcare workers should wear a mask when caring for a patient on droplet precautions or when providing care to patients who are immunocompromised. A surgical mask is worn over the nose and mouth to prevent the transmission of large particle droplet matter generated through coughing or splash-generating procedures. These masks have either ear loops or ties and can be either pleated or made of molded material. An N95 respirator mask is a tight-fitting cover that, when properly fitted, protects the wearer from very small particles that float in the air, such as tuberculosis (TB), measles, chickenpox, and COVID-19 (Figure 6.7). When properly worn, an N95 mask can block at least 95 percent of non-oil-based particles that are 0.3 microns or larger. Any time a mask becomes wet from exhaled moist air, it weakens the integrity of the mask, warranting a mask change.

An infographic titled “Three Key Factors Required for a Respirator to be Effective” is shown. It shows images of a mask being correctly worn and incorrectly worn. It includes the following three factors: 1, The respirator must be put on correctly and worn during the exposure; 2, The respirator must fit snugly against the user’s face to ensure that there are not gaps between the user’s skin and respirator seal; 3, The respirator filter must capture more than 95 percent of the particles from the air that passes through it.
Figure 6.7 While the N95 respirator can be highly effective at stopping particles from passing through, it must fit tightly on the wearer’s face and must be donned and doffed properly in order to provide optimal protection. (credit: modification of “Three Key Factors Required for a Respirator to be Effective” by Centers for Disease Control and Prevention, Public Domain)

Eyewear and Shields

The use of eyewear and shields form a barrier and protect the membranes of the eyes, nose, and mouth when performing tasks that could produce splashes of bodily fluids or blood. Goggles should fit snugly around the eyes and protective face shields should cover the entire forehead, extend past the chin, and wrap around the sides of the face (Figure 6.8).

Image (a) shows a healthcare worker wearing protective goggles, while image (b) shows a healthcare worker wearing a face shield.
Figure 6.8 (a) Goggles and (b) face shield add protection for healthcare providers. These can be worn with additional PPE, while considering placement and appropriate use of each item. (credit a: "CCP treats 1st hospitalized, COVID-positive GAFB member" by Senior Airman Abbey Rieves, Public Domain; credit b: "UAMTF 352-1 assists Philadelphia health care workers" by U.S. Army photo by Pfc. Joshua Cowden, 22nd Mobile Public Affairs Detachment, Public Domain)

Donning PPE

The type of PPE used in a healthcare setting is based on the level of precaution and isolation that is required. The meticulous use of PPE is a vital step to reduce contamination and transfer of infectious diseases. The CDC recommends a standardized procedure for donning, or applying, PPE, but the procedure should always be tailored to the specific type of PPE being used. Prior to donning PPE, always perform hand hygiene. The steps for donning PPE should follow the guidelines outlined by the CDC.

Clinical Safety and Procedures (QSEN)

QSEN Competency: Donning Personal Protective Equipment, Evidence-Based Practice

Definition: Quality and Safety Education for Nurses (QSEN) competencies were designed to emphasize key elements that pre-licensure nursing students should be competent in at the time of graduation. Employing evidence-based practice means “integrating best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.”

Clinical scenario: Here are some evidence-based steps issued by the CDC (n.d.) on donning PPE:

Step 1: An isolation gown should be donned first. The gown should be picked up by the shoulders, which allows it to fall open without touching the floor. The gown should be positioned to fully cover the torso (from the neck to the knees) and arms (to wrists), and it should wrap around the back. Fasten the ties at the neck and the waist.

Step 2: After securing the gown, don the face mask or N95 mask. Ensure that the ties or elastic band fits at the middle of the head and neck. The mask should be snug to the face and below the chin. N95 masks should be fit checked to ensure proper seal.

Step 3: Once the face mask is in place, goggles will be placed over the top of the edge of the mask. A face shield is placed over the eyes.

Step 4: The final step for donning PPE is the application of gloves. The glove cuff should extend over the gown cuff. Ensure that the correct size gloves are selected to prevent them from falling off or ripping.

Doffing and Disposal of PPE

Once patient care is completed, all PPE except for a respirator will be removed, or doffed, prior to exiting a patient’s room. All PPE is discarded in the appropriate receptacle as outlined by facility policy. Following the removal of PPE, perform hand hygiene immediately. The steps for doffing PPE should follow the guidelines outlined by the CDC.

Clinical Safety and Procedures (QSEN)

QSEN Competency: Hand Hygiene and Donning and Doffing PPE

See the competency checklist for Hand Hygiene and Donning and Removing PPE. You can find the checklists on the Student resources tab of your book page on openstax.org.

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