Procedures and Rationale

HANDWASHING
PROCEDURE RATIONALE
Assess the hands:
• Nails should be kept short. Most agencies do not Short, natural nails are less likely
permit health care workers in direct contact with to harbor microorganisms, scratch a client, or
clients to have any form of artificial nails. The CDC puncture gloves.
guidelines prohibit artificial nails in caring for high-risk
clients, and the WHO guidelines prohibit artificial
nails in all settings.
• Removal of all jewelry is recommended Although the research is controversial,

microorganisms can lodge in the settings of jewelry
and under rings. Removal facilitates proper cleaning
of the hands and arm
• Check hands for breaks in the skin, such as A nurse who has open sores may require a work
hangnails or cuts assignment with decreased risk for transmission of
infectious organisms due to the chance of acquiring
or passing on an infection.
Performance
1. If you are washing your hands where the client can

observe you, introduce yourself and explain to the
client what you are going to do and why it is
necessary.
2. Turn on the water and adjust the flow.
• Adjust the flow so that the water is warm. Warm water removes less of the protective oil of the
skin than hot water.
3. Wet the hands thoroughly by holding them under

the running water and apply soap to the hands.
• Hold the hands lower than the elbows so that the The water should flow from the least contaminated to
water flows from the arms to the fingertips the most contaminated
area; the hands are generally considered more
contaminated than the lower arms
• If the soap is liquid, apply 4 to 5 mL (1 tsp). If it is

bar soap, granules, or sheets, rub them firmly
between the hands.
4. Thoroughly wash and rinse the hands.
• Use firm, rubbing, and circular movements to wash The circular action creates friction that helps
the palm, back, and wrist of each hand. Be sure to remove microorganisms mechanically. Interlacing the
include the heel of the hand. Interlace the fingers and fingers
thumbs, and move the hands back and forth. and thumbs cleans the interdigital spaces.
a. Right palm over left dorsum with interlaced fingers

and vice versa
b. Palm to palm with fingers interlaced
c. Backs of fingers to opposing palms with fingers
interlocked
d. Rotational rubbing of left thumb clasped in right
palm and vice versa.
Continue these motions for about 30 seconds.
• Rub the fingertips against the palm of the opposite The nails and fingertips are commonly missed
hand. during hand hygiene.
• Rinse the hands.
5. Thoroughly pat dry the hands and arms.
• Dry hands and arms thoroughly with a paper towel Moist skin becomes chapped readily as does dry
without scrubbing. skin that is rubbed vigorously; chapping produces
lesions
• Discard the paper towel in the appropriate container
6. Turn off the water.
• Use a new paper towel to grasp a hand-operated

control.
This prevents the nurse from picking up
•Apply hand lotion if desired. Use only agency microorganisms from the faucet handles.
approved hand lotions and dispensers. Other lotions
may make hand hygiene less effective, cause the Hand lotions are important to prevent
breakdown of latex gloves, and become skin dryness and irritation.
contaminated with bacteria if dispensers are
refilled.
Variation: Hand Washing Before Performing Sterile

Skills
• Apply the soap and wash as described in step 4, but

hold the hands higher than the elbows during this
hand wash. Wet the hands and forearms under the In this way, the water runs from the area that
running water, letting it run from the fingertips to the now has the fewest microorganisms to areas with a
elbows so that the hands become cleaner than the relatively greater number of pathogens.
elbows.
• After washing and rinsing, use a towel to dry one

hand thoroughly in a rotating motion from the fingers
to the elbow. Use a new towel to dry the other hand
and arm. A clean towel prevents the transfer of
microorganisms
from one elbow (least clean area) to the other hand
• Apply sterile gloves before touching any unsterile (cleanest area).
items
Applying and Removing Personal Protective Equipment (Gloves, Gown, Mask, Eyewear)
PROCEDURE RATIONALE
Preparation
Remove or secure all loose items such as name tags

or jewelry.
Performance
1. Prior to performing the procedure, introduce self

and verify the client’s identity using agency protocol.
Explain to the client what you are going to do, why it
is necessary, and how he or she can participate.
2. Perform hand hygiene.
3. Apply a clean gown.
• Pick up a clean gown, and allow it to unfold in front

of you without allowing it to touch any area soiled
with body substances.
• Slide the arms and the hands through the sleeves.
• Fasten the ties at the neck to keep the gown in

place.
• Overlap the gown at the back as much as possible, Overlapping securely covers the uniform at the back.
and fasten the waist ties or belt. Waist ties keep the gown from falling away from the
body, which can cause inadvertent soiling of the
uniform.
4. Apply the face mask.
• Locate the top edge of the mask. The mask usually

has a narrow metal strip along the edge.
• Hold the mask by the top two strings or loops.
• Place the upper edge of the mask over the bridge of

the nose, and tie the upper ties at the back of the With the edge of the mask under the glasses,
head or secure the loops around the ears. If glasses clouding of the glasses is less likely to occur.
are worn, fit the upper edge of the mask under the
glasses.
• Secure the lower edge of the mask under the chin,

and tie the lower ties at the nape of the neck. To be effective, a mask must cover both the nose
and the mouth, because air moves in and out of both.
• If the mask has a metal strip, adjust this firmly over
A secure fit prevents both the escape and the
the bridge of the nose inhalation of microorganisms around the edges of the
mask and the fogging of eyeglasses.
• Wear the mask only once, and do not wear any
mask longer than the manufacturer recommends or A mask should be used only once because
once it becomes wet. it becomes ineffective when moist.
• Do not leave a used face mask hanging around the

neck.
• The Practice Guidelines provide further instructions

on applying a face mask.
5. Apply protective eyewear if it is not combined with

the face mask.
6. Apply clean gloves.
• No special technique is required.
• If wearing a gown, pull the gloves up to cover the

cuffs of the gown. If not wearing a gown, pull the
gloves up to cover the wrists.
7. To remove soiled PPE, remove the gloves first

since they are the most soiled.
• If wearing a gown that is tied at the waist in front,

undo the ties before removing gloves.
• Remove the first glove by grasping it on its palmar

surface, taking care to touch only glove to glove. This keeps the soiled parts of the used gloves from
touching the skin of the wrist or hand.
• Pull the first glove completely off by inverting or
rolling the glove inside out.
• Continue to hold the inverted removed glove by the

fingers of the remaining gloved hand. Place the first Touching the outside of the second soiled
two fingers of the bare hand inside the cuff of the glove with the bare hand is avoided.
second glove.
•Pull the second glove off to the fingers by turning it

inside out. This pulls the first glove inside the second The soiled part of the glove is folded to the inside
glove. to reduce the chance of transferring any
• Using the bare hand, continue to remove the microorganisms by
gloves, which are now inside out, and dispose of direct contact.
them in the refuse container
8. Perform hand hygiene
Contact with microorganisms may occur while

9. Remove protective eyewear and dispose of removing PPE.
properly or place in the appropriate receptacle for
cleaning.
10. Remove the gown when preparing to leave the

room.
• Avoid touching soiled parts on the outside of the

gown, if possible.
The top part of the gown may be
soiled, for example, if you have been holding an
• Grasp the gown along the inside of the neck and infant with a respiratory infection
pull down over the shoulders. Do not shake the
gown.
• Roll up the gown with the soiled part inside, and

discard it in the appropriate container.
11. Remove the mask.
• Remove the mask at the doorway to the client’s

room. If using a respirator mask, remove it after
leaving the room and closing the door.
• If using a mask with strings, first untie the lower

strings of the mask.
• Untie the top strings and, while holding the ties This prevents the top part of the mask from falling
securely, remove the mask from the face. If side onto the chest.
loops are present, lift the side loops up and away
from the ears and face. Do not touch the front of the The front of the mask through which the nurse has
mask. been breathing is contaminated.
• Discard a disposable mask in the waste container.
• Perform proper hand hygiene again

Establishing and Maintaining a Sterile Field
PROCEDURE RATIONALE

Procedures and Rationale

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HANDWASHING

• Removal of all jewelry is recommended Although the research is controversial,

1. If you are washing your hands where the client can

2. Turn on the water and adjust the flow.

3. Wet the hands thoroughly by holding them under

• If the soap is liquid, apply 4 to 5 mL (1 tsp). If it is

a. Right palm over left dorsum with interlaced fingers

Continue these motions for about 30 seconds.

• Rinse the hands.

5. Thoroughly pat dry the hands and arms.

• Discard the paper towel in the appropriate container

6. Turn off the water.

• Use a new paper towel to grasp a hand-operated

Variation: Hand Washing Before Performing Sterile

• Apply the soap and wash as described in step 4, but

• After washing and rinsing, use a towel to dry one

Remove or secure all loose items such as name tags

1. Prior to performing the procedure, introduce self

2. Perform hand hygiene.

3. Apply a clean gown.

• Pick up a clean gown, and allow it to unfold in front

• Slide the arms and the hands through the sleeves.

• Fasten the ties at the neck to keep the gown in

• Locate the top edge of the mask. The mask usually

• Hold the mask by the top two strings or loops.

• Place the upper edge of the mask over the bridge of

• Secure the lower edge of the mask under the chin,

• Do not leave a used face mask hanging around the

• The Practice Guidelines provide further instructions

5. Apply protective eyewear if it is not combined with

6. Apply clean gloves.

• No special technique is required.

• If wearing a gown, pull the gloves up to cover the

7. To remove soiled PPE, remove the gloves first

• If wearing a gown that is tied at the waist in front,

• Remove the first glove by grasping it on its palmar

• Continue to hold the inverted removed glove by the

•Pull the second glove off to the fingers by turning it

8. Perform hand hygiene

Contact with microorganisms may occur while

10. Remove the gown when preparing to leave the

• Avoid touching soiled parts on the outside of the

• Roll up the gown with the soiled part inside, and

11. Remove the mask.

• Remove the mask at the doorway to the client’s

• If using a mask with strings, first untie the lower

• Discard a disposable mask in the waste container.

• Perform proper hand hygiene again

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