Chapter 14

DIVERSIFIED
HEALTH
OCCUPATIONS
Seventh Edition
Louise Simmers, MEd, RN

Karen Simmers-Nartker, BSN, RN
Sharon Simmers-Kobelak, BBA
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CHAPTER 14 Infection Control
Chapter Objectives
After completing this chapter,
you should be able to:
Observe Standard ◆ Identify five classes of microorganisms by
Precautions describing the characteristics of each class
◆ List the 6 components of the chain of infection
◆ Differentiate between antisepsis, disinfection,
Instructor’s Check—Call
Instructor at This Point and sterilization
◆ Define bioterrorism and identify at least four
ways to prepare for a bioterrorism attack
Safety—Proceed with ◆ Wash hands following aseptic technique
Caution ◆ Observe standard precautions while working
in the laboratory or clinical area
OBRA Requirement—Based
◆ Wash, wrap, and autoclave instruments, linen,
on Federal Law and equipment
◆ Operate an autoclave with accuracy and safety
◆ Follow basic principles on chemical disinfection
Math Skill ◆ Clean instruments with an ultrasonic unit
◆ Open sterile packages with no contamination
◆ Don sterile gloves with no contamination
Legal Responsibility
◆ Prepare a sterile dressing tray with no
contamination
Science Skill ◆ Change a sterile dressing with no
contamination
◆ Don and remove a transmission-based
Career Information isolation mask, gloves, and gown
◆ Relate specific basic tasks to the care of a
Communications Skill
patient in a transmission-based isolation unit
◆ Define, pronounce, and spell all key terms
Technology
Infection Control 351
KEY TERMS
acquired immune deficiency contaminated pathogens (path⬘-oh-jenz⬙)
syndrome (AIDS) disinfection personal protective
aerobic droplet precautions equipment (PPE)
airborne precautions endogenous portal of entry
anaerobic epidemic portal of exit
antisepsis (ant⬙-ih-sep⬘-sis) exogenous protective (reverse) isolation
asepsis (a-sep⬘-sis) fomites protozoa (pro-toe-zo⬘-ah)
autoclave fungi (fun⬘-guy) reservoir
bacteria helminths rickettsiae (rik-et⬘-z-ah)
bioterrorism hepatitis B standard precautions
causative agent hepatitis C sterile
cavitation microorganism (my-crow- sterile field
(kav⬙-ih-tay⬘-shun) or⬘-gan-izm) sterilization
chain of infection mode of transmission susceptible host
chemical disinfection nonpathogens transmission-based
clean nosocomial isolation precautions
communicable disease opportunistic ultrasonic
contact precautions pandemic viruses
14:1 INFORMATION For example, a bacterium called Escherichia coli

(E. coli) is part of the natural flora of the large
Understanding the Principles intestine. If E. coli enters the urinary system,
of Infection Control however, it causes an infection.
To grow and reproduce, microorganisms need
Understanding the basic principles of certain things. Most microorganisms prefer a
infection control is essential for any warm environment, and body temperature is ideal.
health care worker in any field of health care. The Darkness is also preferred by most microorgan-
principles described in this unit provide a basic isms, and many are killed quickly by sunlight. In
knowledge of how disease is transmitted and the addition, a source of food and moisture is needed.
main ways to prevent disease transmission. Some microorganisms, called aerobic organisms,
A microorganism, or microbe, is a small, require oxygen to live. Others, called anaerobic
living organism that is not visible to the naked organisms, live and reproduce in the absence of
eye. It must be viewed under a microscope. oxygen. The human body is the ideal supplier of all
Microorganisms are found everywhere in the the requirements of microorganisms.
environment, including on and in the human
body. Many microorganisms are part of the nor-
mal flora (plant life adapted for living in a specific
environment) of the body and are beneficial in CLASSES OF
maintaining certain body processes. These are
called nonpathogens. Other microorganisms
MICROORGANISMS
cause infection and disease and are called patho- There are many different classes of microorgan-
gens, or germs. At times, a microorganism that is isms. In each class, some of the microorganisms
beneficial in one body system can become patho- are pathogenic to humans. The main classes
genic when it is present in another body system. include:
352 CHAPTER 14
♦ Bacteria: These are simple, one-celled organ- Flagellated

forms
isms that multiply rapidly. They are classified
by shape and arrangement. Cocci are round or Bacilli
spores
spherical in shape (figure 14-1). If cocci occur
in pairs, they are diplococci. Diplococci bacte-
ria cause diseases such as gonorrhea, menin-
gitis, and pneumonia. If cocci occur in chains,
they are streptococci. A common streptococ-
cus causes a severe sore throat (strep throat)
and rheumatic fever. If cocci occur in clusters
or groups, they are staphylococci. These are
the most common pyogenic (pus-producing)
microorganisms. Staphylococci cause infec-
tions such as boils, urinary tract infections,
wound infections, and toxic shock. Rod-
shaped bacteria are called bacilli (figure 14-2).
They can occur singly, in pairs, or in chains.
Many bacilli contain flagella, which are thread-
like projections that are similar to tails and Bacilli
allow the organisms to move. Bacilli also have FIGURE 14-2 Bacilli bacteria.
the ability to form spores, or thick-walled cap-
sules, when conditions for growth are poor. In
Vibrios
the spore form, bacilli are extremely difficult
to kill. Diseases caused by different types of
bacilli include tuberculosis, tetanus, pertussis,
(whooping cough), botulism, diphtheria, and
typhoid. Bacteria that are spiral or corkscrew
in shape are called spirilla (figure 14-3). These
include the comma-shaped vibrio and the
corkscrew-shaped spirochete. Diseases caused
by spirilla include syphilis and cholera. Anti-
biotics are used to kill bacteria. However, some
strains of bacteria have become antibiotic-
Streptococci Staphylococci
Spirilla Spirochetes
FIGURE 14-3 Spirilla bacteria.
resistant, which means that the antibiotic is

no longer effective against the bacteria.
Methicillin-resistant staphylococcus is an
example. It causes a severe Staph infection
that is difficult to treat because it is resistant to
many different antibiotics.
♦ Protozoa: These are one-celled animal-like
Diplococci Micrococci organisms often found in decayed materials,
FIGURE 14-1 Kinds of cocci bacteria. animal or bird feces, insect bites, and con-
taminated water (figure 14-4). Many contain these insects. Rickettsiae cause diseases such
flagella, which allow them to move freely. as typhus fever and Rocky Mountain spotted
Some protozoa are pathogenic and cause dis- fever. Antibiotics are effective against many
eases such as malaria, amebic dysentery different rickettsiae.
(intestinal infection), trichomonas, and Afri- ♦ Viruses: These are the smallest micro-
can sleeping sickness. organisms, visible only using an electron
♦ Fungi: These are simple, plantlike organisms microscope (figure 14-6A and B). They cannot
that live on dead organic matter. Yeasts and reproduce unless they are inside another liv-
molds are two common forms that can be ing cell. They are spread from human to
pathogenic. They cause diseases such as ring- human by blood and other body secretions. It
worm, athlete’s foot, histoplasmosis, yeast is important to note that viruses are more dif-
vaginitis, and thrush (figure 14-5). Antibiotics ficult to kill because they are resistant to many
do not kill fungi. Antifungal medications are disinfectants and are not affected by antibiot-
available for many of the pathogenic fungi, ics. Viruses cause many diseases including the
but they are expensive, must be taken inter- common cold, measles, mumps, chicken pox,
nally for a long period, and may cause liver herpes, warts, influenza, and polio. New and
damage. different viruses emerge constantly because
♦ Rickettsiae: These are parasitic microorgan- viruses are prone to mutating and changing
isms, which means they cannot live outside genetic information. In addition, viruses that
the cells of another living organism. They are infect animals can mutate to infect humans,
commonly found in fleas, lice, ticks, and mites, often with lethal results. There are many
and are transmitted to humans by the bites of examples of these viruses. Severe acute respi-
FIGURE 14-4 An intestinal protozoan, FIGURE 14-6A Electron micrographs of the

Entamoeba coli. (Courtesy of the Centers for various types of herpes simplex virus. (Courtesy of
Disease Control and Prevention, Atlanta, GA) the Centers for Disease Control and Prevention,
Atlanta, GA)
FIGURE 14-5 The yeast (fungus) called thrush FIGURE 14-6B Electron micrograph of the hepati-
causes these characteristic white patches on the tis B virus. (Courtesy of the Centers for Disease
tongue. Control and Prevention, Atlanta, GA)
354 CHAPTER 14
ratory syndrome (SARS) is caused by a variant drome (AIDS). Hepatitis B, or serum hepatitis,
of the coronavirus family that causes the com- is caused by the HBV virus and is transmitted
mon cold. It is characterized by flu-like symp- by blood, serum, and other body secretions. It
toms that can lead to respiratory failure and affects the liver and can lead to the destruc-
death. West Nile virus (WNV) is a mosquito- tion and scarring of liver cells. A vaccine has
borne flavivirus that first infected birds but been developed to protect individuals from
now infects humans. In some individuals, it this disease. The vaccine is expensive and
causes only a mile febrile illness. In other indi- involves a series of three injections. Under
viduals who are older or have poor immune federal law, employers must provide the vac-
systems, it can cause severe neurologic ill- cination at no cost to any health care worker
nesses such as encephalitis or meningitis, with occupational exposure to blood or other
which can lead to death. Monkeypox, a hanta- body secretions that may carry the HBV virus.
virus that affects monkeys, other primates, An individual does have the right to refuse the
and rodents, mutated and spread to humans. vaccination, but a written record must be kept
Infection usually occurs after contacting body proving that the vaccine was offered. Hepati-
secretions or excretions (urine and stool) of tis C is caused by the hepatitis C virus, or HCV,
infected animals or ingesting food that has and is transmitted by blood and blood-con-
been contaminated by fluids from infected taining body fluids. Many individuals who
animals. A major outbreak occurred in the contract the disease are asymptomatic (dis-
American southwest when infected prairie play no symptoms); others have mild symp-
dogs contaminated food with fecal material. toms that are often diagnosed as influenza or
Monkeypox is similar to smallpox. It causes flu. In either case, HCV can cause serious liver
severe flu-like symptoms, lymphadenopathy damage. At present, there is no preventive
(disease of the lymph nodes), and pustules immunization, but a vaccine is being devel-
that cause severe scarring of the skin. If the oped. Both HBV and HCV are extremely diffi-
eyes are infected, blindness can occur. It can cult to destroy. These viruses can even remain
be prevented and/or treated with a smallpox active for several days in dried blood. Health
vaccination. Filoviruses such as Ebola and care workers must take every precaution to
Marburg first affected primates and then protect themselves from hepatitis viruses.
spread to humans. These viruses cause hem- Acquired immune deficiency syndrome
orrhagic fever, a disease that begins with fever, is caused by the human immunodeficiency
chills, headache, myalgia (muscle pain), and a virus (HIV) and suppresses the immune sys-
skin rash. It quickly progresses to jaundice, tem. An individual with AIDS cannot fight off
pancreatitis, liver failure, massive hemorrhag- many cancers and infections that would not
ing throughout the body, delirium, shock, and affect a healthy person. Presently, there is no
death. Most outbreaks of hemorrhagic fever cure and no vaccine is available, so it is impor-
have been in Africa, but isolated cases have tant for the health care worker to take precau-
appeared in other parts of the world when tions to prevent the spread of this disease.
individuals were in contact with infected pri-
mates. A new H5N1 virus that causes avian or ♦ Helminths: These are multicellular parasitic
bird flu has devastated bird flocks in many organisms commonly called worms or flukes.
countries. The infection has appeared in They are transmitted to humans when humans
humans, but most cases have resulted from ingest the eggs or larvae in contaminated food,
contact with infected poultry or contaminated ingest meat contaminated with the worms, or
surfaces. The spread from one person to get bitten by infected insects. Some worms
another has been reported only rarely. How- can also penetrate the skin to enter the body.
ever, because the death rate for bird flu is Examples of helminths include: hookworms,
between 50 and 60 percent, a major concern is which attach to the small intestine and can
that the H5N1 virus will mutate and spread infect the heart and lungs; ascariasis, which
more readily. In addition to these viruses, there live in the small intestine and can cause an
are three other viral diseases of major concern obstruction of the intestine; trichinella spira-
to the health care worker: hepatitis B, hepati- lis, which causes trichinosis and is contracted
tis C, and acquired immune deficiency syn- by eating raw or inadequately cooked pork
products; enterobiasis, which is commonly

called pinworm and affects mainly young chil- CHAIN OF INFECTION
dren; and taenia solium or pork tapeworm,
For disease to occur and spread from one indi-
which is contracted by eating inadequately
vidual to another, certain conditions must be
cooked pork.
met. These conditions are commonly called the
chain of infection (figure 14-7). The parts of
the chain include:
♦ Causative agent: a pathogen, such as a bac-
TYPES OF INFECTION terium or virus that can cause a disease
Pathogenic microorganisms cause infection and ♦ Reservoir: an area where the causative agent
disease in different ways. Some pathogens pro- can live; some common reservoirs include the
duce poisons, called toxins, which harm the body. human body, animals, the environment, and
An example is the bacillus that causes tetanus, fomites, or objects contaminated with infec-
which produces toxins that damage the central tious material that contains the pathogens.
nervous system. Some pathogens cause an aller- Common fomites include doorknobs, bed-
gic reaction in the body, resulting in a runny nose, pans, urinals, linens, instruments, and speci-
watery eyes, and sneezing. Other pathogens men containers.
attack and destroy the living cells they invade. An ♦ Portal of exit: a way for the causative agent
example is the protozoan that causes malaria. It to escape from the reservoir in which it has
invades red blood cells and causes them to rup- been growing. In the human body, pathogens
ture. can leave the body through urine, feces, saliva,
Infections and diseases are also classified as blood, tears, mucous discharge, sexual secre-
endogenous, exogenous, nosocomial, or oppor- tions, and draining wounds.
tunistic. Endogenous means the infection or
disease originates within the body. These include
♦ Mode of transmission: a way that the caus-
ative agent can be transmitted to another res-
metabolic disorders, congenital abnormalities,
ervoir or host where it can live. The pathogen
tumors, and infections caused by microorgan-
can be transmitted in different ways. One way
isms within the body. Exogenous means the
is by direct contact, which includes person-to-
infection or disease originates outside the body.
person contact (physical or sexual contact) or
Examples include pathogenic organisms that
contact with a body secretion containing the
invade the body, radiation, chemical agents,
pathogen. Contaminated hands are one of the
trauma, electric shock, and temperature extremes.
most common sources of direct contact trans-
A nosocomial infection is one acquired by an
mission. Another way is by indirect contact,
individual in a health care facility such as a hos-
when the pathogen is transmitted from con-
pital or long-term care facility. Nosocomial infec-
taminated substances such as food, air, soil,
tions are usually present in the facility and
insects, feces, clothing, instruments, and
transmitted by health care workers to the patient.
equipment. Examples include touching con-
Many of the pathogens transmitted in this man-
taminated equipment and spreading the
ner are antibiotic-resistant and can cause serious
pathogen on the hands, breathing in droplets
and even life-threatening infections in patients.
carrying airborne infections, and contacting
Common examples are staphylococcus, pseudo-
vectors (insects, rodents, or small animals),
monas, and enterococci. Infection-control pro-
such as being bitten by an insect carrying a
grams are used in health care facilities to prevent
pathogen.
and deal with nosocomial infections. Opportu-
nistic infections are those that occur when the ♦ Portal of entry: a way for the causative agent
body’s defenses are weak. These diseases do not to enter a new reservoir or host. Some ways
usually occur in individuals with intact immune pathogens can enter the body are through
systems. Examples include the development of breaks in the skin, breaks in the mucous mem-
Kaposi’s sarcoma (a rare type of cancer) or Pneu- brane, the respiratory tract, the digestive tract,
mocystis carinii pneumonia in individuals with the genitourinary tract, and the circulatory
AIDS. system. If the defense mechanisms of the body
356 CHAPTER 14
Early recognition of signs of infection

Rapid, accurate identification
of organisms
Medical asepsis
Treatment of Causative Standard precautions
underlying agent
diseases Employee health
Recognition
of high-risk Source Environmental
patients Susceptible or sanitation
host reservoir Disinfection/
Immunization sterilization
to prevent Involves
disease all health
care workers—
YOU
Wound care Portal Portal Medical asepsis

of of
entry exit Personal protective
equipment
Catheter
care Handwashing
Control of excretions
Medical Mode of & secretions
asepsis transmission Trash & waste
Standard disposal
precautions Standard Standard precautions
precautions
Handwashing Transmission-based precautions
Sterilization Food handling

Medical asepsis Air flow control
FIGURE 14-7 Note the components in the chain of infection and the ways in which the chain can be broken.
are intact and the immune system is function- ♦ Susceptible host: a person likely to get an
ing, a human can frequently fight off the caus- infection or disease, usually because body
ative agent and not contract the disease. Body defenses are weak
defenses include:
mucous membrane: lines the respiratory, Health care workers must constantly be aware
digestive, and reproductive tracts and traps of the parts in the chain of infection. If any part of
pathogens the chain is eliminated, the spread of disease or
cilia: tiny, hairlike structures that line the infection will be stopped. A health care worker
respiratory tract and propel pathogens out of who is aware of this can follow practices to inter-
the body rupt or break this chain and prevent the trans-
coughing and sneezing mission of disease. It is important to remember
hydrochloric acid: destroys pathogens in the that pathogens are everywhere and that prevent-
stomach ing their transmission is a continuous process.
tears in the eye: contain bacteriocidal (bacteria-
killing) chemicals
fever
ASEPTIC TECHNIQUES
inflammation: leukocytes, or white blood A major way to break the chain of infection is to
cells, destroy pathogens use aseptic techniques while providing health
immune response: body produces antibodies, care. Asepsis is defined as the absence of dis-
protective proteins that combat pathogens, ease-producing microorganisms, or pathogens.
and protective chemicals secreted by cells, Sterile means free from all organisms, both
such as interferon and complement pathogenic and nonpathogenic, including spores
and viruses. Contaminated means that organ- ganisms have been used in biologic warfare.
isms and pathogens are present. Any object or Some examples include:
area that may contain pathogens is considered to
♦ The Tartar army throwing bodies of dead
be contaminated. Aseptic techniques are directed
plague victims over the walls of a city called
toward maintaining cleanliness and eliminating
Caffa in 1346, causing an epidemic of plague
or preventing contamination. Common aseptic
in the city
techniques include handwashing, good personal
hygiene, use of disposable gloves when contact- ♦ The British army providing Delaware Indians
ing body secretions or contaminated objects, with blankets and handkerchiefs contami-
proper cleaning of instruments and equipment, nated with smallpox in 1763, resulting in a
and thorough cleaning of the environment. major outbreak of smallpox among the Indian
Various levels of aseptic control are possible. population
These include: ♦ The Germans using a variety of animal and
♦ Antisepsis: Antiseptics prevent or inhibit human pathogens in World War I
growth of pathogenic organisms but are not ♦ The Japanese military using prisoners of war
effective against spores and viruses. They can to experiment with many different pathogens
usually be used on the skin. Common exam- in World War II
ples include alcohol and betadine. ♦ The United States, Canada, the Soviet Union,
♦ Disinfection: This is a process that destroys and the United Kingdom developing biologic
or kills pathogenic organisms. It is not always weapons programs until the late 1960s
effective against spores and viruses. Chemical
♦ The release of sarin gas in Tokyo in 1995
disinfectants are used in this process. Disin-
fectants can irritate or damage the skin and ♦ The mail attack with anthrax by an unknown
are used mainly on objects, not people. Some individual or individuals in the United States
common disinfectants are bleach solutions in 2001
and zephirin. Today, there is a major concern that these bio-
♦ Sterilization: This is a process that destroys logic agents will be used not only in wars, but also
all microorganisms, both pathogenic and against unsuspecting civilians.
nonpathogenic, including spores and viruses.
Steam under pressure, gas, radiation, and
chemicals can be used to sterilize objects. An BIOLOGIC AGENTS
autoclave is the most common piece of equip-
ment used for sterilization. Many different microorganisms can cause dis-
eases in humans, animals, and plants. However,
In the sections that follow, correct methods of only a limited number are considered to be ideal
aseptic techniques are described. It is important for bioterrorism. Six characteristics of the “ideal”
for the health care worker to know and use these microorganism include:
methods in every aspect of providing health care
to prevent the spread and transmission of disease. ♦ Inexpensive and readily available or easy to
produce
STUDENT: Go to the workbook and complete ♦ Spread through the air by winds or ventilation
the assignment sheet for 14:1, Understanding the systems and inhaled into the lungs of poten-
Principles of Infection Control. tial victims, or spread by ingesting contami-
nated food or water
14:2 INFORMATION ♦ Survives sunlight, drying, and heat
Bioterrorism ♦ Causes death or severe disability
♦ Easily transmitted from person to person
INTRODUCTION ♦ Difficult to prevent and/or has no effective
treatment
Bioterrorism is the use of microorganisms, or
biologic agents, as weapons to infect humans, The Centers for Disease Control and Preven-
animals, or plants. Throughout history, microor- tion (CDC) has identified and classified major
358 CHAPTER 14
bioterrorism agents. High-priority agents that ♦ Plague: This is an infectious disease that is
have been identified include: caused by bacteria called Yersinia pestis. Usu-
♦ Smallpox: Smallpox is a highly contagious ally plague is transmitted by the bites of
infectious disease that is caused by a variola infected fleas. In some cases, the organism
virus. A smallpox vaccination can provide pro- enters the body through a break in the skin or
tection against some types of smallpox, but by contact with tissue of an infected animal.
one type, hemorrhagic smallpox, is usually Rats, rock squirrels, prairie dogs, and chip-
fatal. Until the 1970s, people were vaccinated munks are the most common sources for
against smallpox. However, after many years plague in the United States. If the disease is
with no reported cases, the vaccinations were not treated immediately with antibiotics, the
no longer required. Now, with the threat of a infection spreads to the blood and lungs, and
smallpox bioterrorism attack, the U.S. govern- causes death. No vaccine for plague is avail-
ment has started a new vaccination program. able in the United States.
The program encourages first responders, ♦ Botulism: Botulism is a paralytic illness caused
police, fire department, and health care per- by a nerve toxin produced by bacteria called
sonnel to be vaccinated. Clostridium botulinum. Three main types of
♦ Anthrax: Anthrax is an infectious disease botulism exist. One type is caused by eating
caused by the spores of bacteria called Bacil- foods that contain the toxin. A second type is
lus anthracis. The spores are highly resistant caused by the presence of the toxin in a wound
to destruction and can live in soil for years. or injury to the skin. A third type occurs in
Grazing animals such as cattle, sheep, and infants who eat the spores that then grow in
goats eat the contaminated soil and become the intestine and release the toxin. The toxin
infected. Humans develop anthrax by expo- rapidly causes muscle paralysis. If it is not
sure through the skin (cutaneous) (figure treated with an antitoxin, the paralysis spreads
14-8), by eating undercooked or raw infected to the respiratory muscles and causes death.
meat (gastrointestinal), or by inhaling the ♦ Tularemia: This is an infectious disease caused
spores (pulmonary). Cutaneous and gastroin- by bacteria called Francisella tularensis. This
testinal anthrax are usually treated success- bacteria is commonly found in animals such
fully with antibiotics, but some victims die. as rats, rabbits, and insects (ticks and deer-
Inhalation anthrax causes death in more than flies). Humans get the disease through the bite
80 percent of its victims. An anthrax vaccine is of an infected animal or insect, by eating con-
available for prevention. The military has an taminated food, by drinking contaminated
active vaccination program. water, or by breathing in the bacteria. The dis-
ease causes death if it is not treated with
appropriate antibiotics. Currently, the Food
and Drug Administration (FDA) is reviewing a
vaccine, but it is not available in the United
States.
♦ Filoviruses: A filovirus is an infectious disease
that causes severe hemorrhagic fever. Two
filoviruses have been identified. They are the
Ebola viruses and the Marburg virus. The
source of the viruses is still being researched,
but the common belief is that the viruses are
transmitted from animals such as bats. Once
the viruses affect a human, the disease is
spread rapidly from person to person by con-
tact with body fluids. No effective treatment
exists, and 50–90 percent of infected individu-
FIGURE 14-8 Cutaneous (skin) anthrax is usually
treated successfully with antibiotics. (Courtesy of als die.
the Centers for Disease Control Public Image Many other pathogenic microorganisms can
Library) be used in a bioterrorism attack. In fact, any
pathogenic organism could be used in a bioter- ♦ Improving communications so information

rorism attack. For this reason, health care work- on bioterrorism is transmitted quickly and
ers must be constantly alert to the threat of efficiently
infection with a biologic agent.
Every health care worker must constantly be alert
to the threat of bioterrorism. In today’s world, it is
PREPARING FOR likely that an attack will occur. Careful prepara-
tion and thorough training can limit the effect of
BIOTERRORISM the attack and save the lives of many people.
A bioterrorism attack could cause an epidemic STUDENT: Go to the workbook and complete
and public health emergency. Large numbers of the assignment sheet for 14:2, Bioterrorism.
infected people would place a major stress on
health care facilities. Fear and panic could lead to
riots, social disorder, and disregard for authority.
For these reasons, the Bioterrorism Act of 2002
14:3 INFORMATION
was passed by Congress and signed into law in Washing Hands
June 2002. This act requires the development of a
comprehensive plan against bioterrorism to Handwashing is a basic task required in
increase security in the United States. any health occupation. The method
Preparing for bioterrorism will involve gov- described in this unit has been developed to
ernment at all levels—local, regional, state, and ensure that a thorough cleansing occurs. An asep-
national. Some of the major aspects of prepara- tic technique is a method followed to prevent the
tion include: spread of germs or pathogens. Handwashing is
the most important method used to practice asep-
♦ Community-based surveillance to detect early tic technique. Handwashing is also the most effec-
indications of a bioterrorism attack tive way to prevent the spread of infection.
♦ Notification of the public when a high-risk The hands are a perfect medium for the
situation is detected spread of pathogens. Thoroughly washing the
♦ Strict infection-control measures and public hands helps prevent and control the spread of
education about the measures pathogens from one person to another. It also
helps protect the health worker from disease and
♦ Funding for studying pathogenic organisms, illness.
developing vaccines, researching treatments, The Centers for Disease Control and Preven-
and determining preventive actions tion (CDC) published the results of handwashing
♦ Strict guidelines and restrictions for purchas- research and new recommendations for hand
ing and transporting pathologic microorgan- hygiene in 2002. The recommendations call for
isms regular handwashing using plain soap and water,
♦ Mass immunization, especially for military, antiseptic handwashing using an antimicrobial
first responders, police, fire department, and soap and water, and antiseptic hand rubs (water-
health care personnel less handwashing) using alcohol-based hand
cleaners. Regular handwashing is recommended
♦ Increased protection of food and water sup- for routine cleansing of the hands when the hands
plies are visibly dirty or soiled with blood or other body
♦ Training personnel to properly diagnose and fluids. Antiseptic handwashing is recommended
treat infectious diseases before invasive procedures, in critical care units,
♦ Establishing emergency management policies while caring for patients on specific organism
transmission-based precautions, and in specific
♦ Criminal investigation of possible threats circumstances defined by the infection-control
♦ Improving the ability of health care facilities program of the health care facility. Antiseptic hand
to deal with an attack by increasing emer- rubs are recommended if the hands are not visibly
gency department space, preparing decon- dirty or are not soiled with blood or body fluids.
tamination areas, and establishing isolation Handwashing should be performed fre-
facilities quently. It should be done:
360 CHAPTER 14
♦ When you arrive at the facility and immedi- ♦ Dry paper towels must be used to turn the
ately before leaving the facility faucet on and off. This action prevents con-
♦ Before and after every patient contact tamination of the hands from pathogens on
the faucet. A dry towel must be used because
♦ After contact with a patient’s intact skin (for pathogens can travel more readily through a
example, after taking a blood pressure) wet towel.
♦ Before moving from a contaminated body site Nails also harbor dirt and pathogens, and must
to a clean body site during patient care (for
be cleaned during the handwashing process. An
example, before washing the patient’s hands
orange/cuticle stick can be used. Care must be
after removing a bedpan)
taken to use the blunt end of the stick because
♦ Any time the hands become contaminated the pointed end can injure the nailbeds. A brush
during a procedure can also be used to clean the nails. If a brush or
♦ Before applying and immediately after remov- orange stick is not available or the nails are not
ing gloves visibly dirty, the nails can be rubbed against the
palm of the opposite hand to get soap under the
♦ Any time gloves are torn or punctured
nails. Most health care facilities prohibit the use
♦ Before and after handling any specimen of artificial nails and require that nails be kept
♦ After contact with any soiled or contaminated short, usually less than 1/4-inch long. Artificial or
item long nails can harbor organisms and increase the
risk for infection for both the patient and health
♦ After picking up any item off the floor
care worker. In addition, long nails can puncture
♦ After personal use of the bathroom or tear gloves.
♦ After you cough, sneeze, or use a tissue Waterless hand cleaning with an alcohol-
♦ Before and after any contact with your mouth based gel, lotion, or foam has been proved safe for
or mucous membrane, such as eating, drink-
ing, smoking, applying lip balm, or inserting
or removing contact lenses
The recommended method for handwashing
is based on the following principles; they should
be observed whenever hands are washed:
♦ Soap is used as a cleansing agent because it
aids in the removal of germs through its sudsy
action and alkali content. Pathogens are
trapped in the soapsuds and rinsed away. Liq-
uid soap from a dispenser should be used
whenever possible because bar soap can con-
tain microorganisms. Image not available due to copyright restrictions
♦ Warm water should be used. This is less dam-
aging to the skin than hot water. It also creates
a better lather with soap than does cold
water.
♦ Friction must be used in addition to soap and
water. This action helps rub off pathogens
from the surface of the skin.
♦ All surfaces on the hands must be cleaned.
This includes the palms, the backs/tops of the
hands, and the areas between the fingers.
♦ Fingertips must be pointed downward. The
downward direction prevents water from get-
ting on the forearms and then running down
to contaminate the clean hands.
use during routine patient care. Its use is recom- the hands be washed with soap and water after
mended when the hands are not visibly dirty and 6–10 cleanings with the alcohol-based product. In
are not contaminated with blood or body fluids addition, if the hands are visibly soiled, or if there
(figure 14-9). Most waterless hand cleaning prod- has been contact with blood or body fluid, the
ucts contain alcohol to provide antisepsis and a hands must be washed with soap and water.
moisturizer to prevent drying of the skin. It is Every health care facility has written policies
important to read the manufacturer’s instructions for hand hygiene as a part of their standard pre-
before using any product. Usually a small amount cautions manual. Health care workers must
of the alcohol-based cleaner is applied to the palm become familiar with and follow these policies to
of the hands. The hands are then rubbed vigor- prevent the spread of infection.
ously so the solution is applied to all surfaces of
the hands, fingers, nails, and wrists. The hands STUDENT: Go to the workbook and complete
should be rubbed until they are dry, usually at least the assignment sheet for 14:3, Washing Hands.
15 seconds. Most manufacturers recommend that Then return and continue with the procedure.
PROCEDURE 14:3
forearms and then running back down
Washing Hands to contaminate hands.
4. Use soap to get a lather on your hands.
Equipment and Supplies
5. Put the palms of your hands together
Paper towels, running water, waste container, and rub them using friction and a circu-
hand brush or orange/cuticle stick, soap lar motion for at least 15 seconds.
Procedure 6. Put the palm of one hand on the back of

the other hand. Rub together several
1. Assemble all equipment. Stand back times. Repeat this after reversing posi-
slightly from the sink so you do not con- tion of hands (figure 14-10B).
taminate your uniform or clothing. 7. Interlace the fingers on both hands and
Avoid touching the inside of the sink rub them back and forth (figure 14-10C).
with your hands since it is considered
8. Encircle your wrist with the palm and
contaminated. Remove any rings and
fingers of the opposite hand. Use a cir-
push your wristwatch up above your
cular motion to clean the front, back,
wrist.
and sides of the wrist. Repeat for the
2. Turn the faucet on by holding a paper opposite wrist.
towel between your hand and the faucet
9. Clean the nails with an orange/cuticle
(figure 14-10A). Regulate the tempera-
stick and/or hand brush if they are visi-
ture of the water and let water flow over
bly dirty or if this is the first hand clean-
your hands. Discard the towel in the
ing of the day (figures 14-10D and E). If
waste container.
the nails are not visibly dirty, they can
NOTE: Water should be warm. be cleaned by rubbing them against the
CAUTION: Hot water will burn your palm of the opposite hand.
hands. CAUTION: Use the blunt end of orange/
3. With your fingertips pointing down- cuticle stick to avoid injury.
ward, wet your hands. NOTE: Steps 3 through 9 ensure that all
NOTE: Washing in a downward direc- parts of both hands are clean.
tion prevents water from getting on the
362 CHAPTER 14
PROCEDURE 14:3
FIGURE 14-10A Use a dry FIGURE 14-10B Point the FIGURE 14-10C Interlace
towel to turn the faucet on. fingertips downward and use the the fingers to clean between
palm of one hand to clean the the fingers.
back of the other hand.
FIGURE 14-10D The blunt FIGURE 14-10E A hand FIGURE 14-10F With the
end of an orange stick can be brush can also be used to clean fingertips pointing downward,
used to clean the nails. the nails. rinse the hands thoroughly.
10. Rinse your hands from the forearms
down to the fingertips, keeping finger-
tips pointed downward (figure 14-10F).
11. Use a clean paper towel to dry hands
Practice
Go to the workbook and use the
thoroughly, from tips of fingers to wrist. evaluation sheet for 14:3, Washing
Discard the towel in the waste con- Hands, to practice this procedure.
tainer. When you believe you have
12. Use another dry paper towel to turn off mastered this skill, sign the sheet
the faucet. and give it to your instructor for
CAUTION: Wet towels allow passage of further action.
pathogens.
13. Discard all used towels in the waste con-
tainer. Leave the area neat and clean.
Final Checkpoint Using the criteria
14. Apply a water-based hand lotion if listed on the evaluation sheet, your
desired. instructor will grade your performance.
face that comes in contact with blood or infec-

14:4 Information tious materials, and dispose of infectious
waste correctly.
Observing Standard Precautions
♦ Enforce rules of no eating, drinking, smoking,
To prevent the spread of pathogens and applying cosmetics or lip balm, handling con-
disease, the chain of infection must be tact lenses, and mouth pipetting or suctioning
broken. The standard precautions discussed in in any area that can be potentially contami-
this unit are an important way health care work- nated by blood or other body fluids.
ers can break this chain.
♦ Provide appropriate containers that are color
coded (fluorescent orange or orange-red) and
labeled for contaminated sharps (needles,
BLOODBORNE scalpels) and other infectious or biohazard
PATHOGENS STANDARD wastes.
♦ Post signs at the entrance to work areas where
One of the main ways that pathogens are spread there is occupational exposure to biohazard-
is by blood and body fluids. Three pathogens of ous materials. Label any item that is biohaz-
major concern are the hepatitis B virus (HBV), ardous with the red biohazard symbol (figure
the hepatitis C virus (HCV), and the human 14-11). The label must show both the symbol
immunodeficiency virus (HIV), which causes and the word “biohazard.”
AIDS. Consequently, extreme care must be taken ♦ Provide a confidential medical evaluation and
at all times when an area, object, or person is follow-up for any employee who has an expo-
contaminated with blood or body fluids. In 1991, sure incident. Examples might include an
the Occupational Safety and Health Administra- accidental needlestick or the splashing of
tion (OSHA) established Bloodborne Pathogen blood or body fluids on the skin, eyes, or
Standards that must be followed by all health care mucous membranes.
facilities. The employer faces civil penalties if the
regulations are not implemented by the employer ♦ Provide training about the regulations and all
and followed by the employees. These regulations potential biohazards to all employees at no
require all health care facility employers to: cost during working hours, and provide addi-
tional education as needed when procedures
♦ Develop a written exposure control plan, and or working conditions are changed or modi-
update it annually, to minimize or eliminate fied.
employee exposure to bloodborne pathogens.
♦ Identify all employees who have occupational
exposure to blood or potentially infectious NEEDLESTICK SAFETY
materials such as semen, vaginal secretions,
and other body fluids.
ACT
♦ Provide hepatitis B vaccine free of charge to all In 2001, OSHA revised its Bloodborne Pathogen
employees who have occupational exposure, Standards in response to Congress passing the
and obtain a written release form signed by Needlestick Safety and Prevention Act in Novem-
any employee who does not want the vac-
cine.
♦ Provide personal protective equipment
(PPE) such as gloves, gowns, lab coats, masks,
and face shields in appropriate sizes and in
accessible locations.
♦ Provide adequate handwashing facilities and
supplies.
♦ Ensure that the worksite is maintained in a
clean and sanitary condition, follow measures FIGURE 14-11 The universal biohazard symbol
for immediate decontamination of any sur- indicates a potential source of infection.
364 CHAPTER 14
ber 2000. This act was passed after the Centers for ♦ Incorporate changes in annual update of expo-
Disease Control and Prevention (CDC) estimated sure control plan. Employers must include
that 600,000 to 800,000 needlesticks occur each changes in technology that eliminate or reduce
year, exposing health care workers to bloodborne exposure to bloodborne pathogens in the
pathogens. Employers are required to: annual update and document the implemen-
♦ Identify and use effective and safer medical tation of any safer medical devices.
devices. OSHA defines safer devices as sharps ♦ Solicit input from nonmanagerial employees
with engineered injury protections and who are responsible for direct patient care.
includes, but is not limited to, devices such as Employees who provide patient care, and are
syringes with a sliding sheath that shields the exposed to injuries from contaminated sharps,
needle after use, needles that retract into a must be included in a multidisciplinary team
syringe after use, shielded or retracting cath- that identifies, evaluates, and selects safer
eters that can be used to administer intrave- medical devices, and determines safer work
nous medications or fluids, and intravenous practice controls.
systems that administer medication or fluids ♦ Maintain a sharps injury log. Employers with
through a catheter port or connector site using more than 11 employees must maintain a
a needle housed in a protective covering (fig- sharps injury log to help identify high-risk
ure 14-12). OSHA also encourages the use of areas and evaluate ways of decreasing inju-
needleless systems, which include, but are not ries. Each injury recorded must protect the
limited to, intravenous medication delivery confidentiality of the injured employee, but
systems that administer medication or fluids must state the type and brand of device
through a catheter port or connector site using involved in the incident, the work area or
a blunt cannula or other non-needle connec- department where the exposure injury
tion, and jet injection systems that deliver occurred, and a description of how the inci-
subcutaneous or intramuscular injections dent occurred.
through the skin without using a needle.
STANDARD
PRECAUTIONS
Employers are also required to make sure that
every employee uses standard precautions at all
times to prevent contact with blood or other
potentially infectious materials. Standard pre-
cautions (figure 14-13) are rules developed by
the CDC. According to standard precautions,
every body fluid must be considered a potentially
infectious material, and all patients must be con-
sidered potential sources of infection, regardless
of their disease or diagnosis. Standard precau-
tions must be used in any situation where health
care providers may contact:
♦ Blood or any fluid that may contain blood
♦ Body fluids, secretions, and excretions, such
as mucus, sputum, saliva, cerebrospinal fluid,
urine, feces, vomitus, amniotic fluid (sur-
FIGURE 14-12 The Safety-Glide syringe is one rounding a fetus), synovial (joint) fluid, pleu-
example of a safer device to prevent needlesticks. ral (lung) fluid, pericardial (heart) fluid,
(Photo reprinted courtesy of BD [Becton Dickinson peritoneal (abdominal cavity) fluid, semen,
and Company]) and vaginal secretions
FIGURE 14-13 Standard precautions must be observed while working with all patients. (Courtesy of Brevis
Corporation)
366 CHAPTER 14
♦ Mucous membranes Care must be taken while removing gloves to

avoid contamination of the skin. Gloves must
♦ Nonintact skin not be washed or disinfected for reuse because
♦ Tissue or cell specimens washing may allow penetration of liquids
The basic rules of standard precautions through undetected holes, and disinfecting
include: agents may cause deterioration of gloves.
♦ Handwashing: Hands must be washed before ♦ Gowns: Gowns must be worn during any pro-
and after contact with any patient. If hands or cedure that is likely to cause splashing or
other skin surfaces are contaminated with spraying of blood, body fluids, secretions, or
blood, body fluids, secretions, or excretions, excretions. This helps prevent contamination
they must be washed immediately and thor- of clothing or uniforms. Contaminated gowns
oughly with soap and water. Hands must must be handled according to agency policy
always be washed immediately before don- and local and state laws. Wash hands immedi-
ning and immediately after removal of gloves. ately after removing a gown.
♦ Gloves: Gloves (figure 14-14) must be worn ♦ Masks and Eye Protection: Masks and protec-
whenever contact with blood, body fluids, tive eyewear or face shields (figure 14-15) must
secretions, excretions, mucous membranes, be worn during procedures that may produce
tissue specimens, or nonintact skin is possi- splashes or sprays of blood, body fluids, secre-
ble; when handling or cleaning any contami- tions, or excretions. Examples include irriga-
nated items or surfaces; when performing any
invasive (entering the body) procedure; and
when performing venipuncture or blood tests.
Rings must be removed before putting on
gloves to avoid puncturing the gloves. Gloves
must be changed after contact with each
patient and even between tasks or procedures
on the same patient if there is any chance the
gloves are contaminated. Hands must be
washed immediately after removal of gloves.
FIGURE 14-15 Gloves, a gown, a mask, and

FIGURE 14-14 Gloves must be worn whenever protective eyewear must be worn during any
contact with blood, body fluids, secretions, excre- procedure that may produce droplets or cause
tions, mucous membranes, or nonintact skin is splashing of blood, body fluids, secretions, or
possible. excretions.
tion of wounds, suctioning, dental procedures, labeled with a red biohazard symbol. Surgical
delivery of a baby, and surgical procedures. blades, razors, and other sharp objects must
This prevents exposure of the mucous mem- also be discarded in the sharps container.
branes of the mouth, nose, and eyes to any The sharps containers must not be emp-
pathogens. tied or reused. Federal, state, and local
Masks must be used once and then dis- laws establish regulations for the disposal of
carded. In addition, masks should be changed sharps containers. In some areas, the filled
every 30 minutes or anytime they become container is placed in a special oven and
moist or wet. They should be removed by melted. The material remaining is packaged as
grasping the ties or elastic strap. Hands must biohazard or infectious waste and disposed of
be washed immediately after the mask is according to legal requirements for infectious
removed. Protective eyewear or face shields waste.
should provide protection for the front, top,
♦ Spills or Splashes: Spills or splashes of blood,
bottom, and sides of the eyes. If eyewear is not
body fluids, secretions, or excretions must be
disposable, it must be cleaned and disinfected
wiped up immediately (figure 14-17). Gloves
before it is reused.
must be worn while wiping up the area with
♦ Sharps: To avoid accidental cuts or punc- disposable cleaning cloths. The area must
tures, extreme care must be taken while then be cleaned with a disinfectant solution
handling sharp objects. Whenever possible, such as a 10-percent bleach solution. Furni-
safe needles or needleless devices must be ture or equipment contaminated by the spill
used. Disposable needles must never be bent or splash must be cleaned and disinfected
or broken after use. They must be left uncapped immediately. For large spills, an absorbent
and attached to the syringe and placed in a powder may be used to soak up the fluid. After
leakproof puncture-resistant sharps container the fluid is absorbed, it is swept up and placed
(figure 14-16). The sharps container must be in an infectious waste container.
FIGURE 14-16 All needles and sharp objects FIGURE 14-17 Gloves must be worn while wiping
must be discarded immediately in a leakproof up any spills of blood, body fluids, secretions, or
puncture-resistant sharps container. excretions.
368 CHAPTER 14
♦ Resuscitation Devices: Whenever possible, container (figure 14-19) and know the require-
mouthpieces or resuscitation devices should ments for disposal. Soiled linen should be
be used to avoid the need for mouth-to-mouth placed in laundry bags to prevent any con-
resuscitation. These devices should be placed tamination. Linen soiled with blood, body flu-
in convenient locations and be readily acces- ids, or excretions is placed in a special bag for
sible for use. contaminated linen and is usually soaked in a
disinfectant prior to being laundered. Gloves
♦ Waste and Linen Disposal: Health care work- must be worn while handling any contami-
ers must wear gloves and follow the agency
nated linen, and any bag containing contami-
policy developed according to law to dispose
nated linen must be clearly labeled and color
of waste and soiled linen. Infectious wastes
coded.
such as contaminated dressings; gloves; uri-
nary drainage bags; incontinent pads; vaginal ♦ Injuries: Any cut, injury, needlestick, or splash-
pads; disposable emesis basins, bedpans, ing of blood or body fluids must be reported
and/or urinals; and body tissues must be immediately. Agency policy must be followed
placed in special infectious waste or biohaz- to deal with the injury or contamination. Every
ardous material bags (figure 14-18) according health care facility must have a policy for stat-
to law. Other trash is frequently placed in plas- ing actions that must be taken immediately
tic bags and incinerated. The health care when exposure or injury occurs, reporting any
worker must dispose of waste in the proper incident, documenting any exposure incident,
recording the care given, noting follow-up to
the exposure incident, and identifying ways to
prevent a similar incident.
Standard precautions must be followed at all
times by all health care workers. By observing
these precautions, health care workers can help
break the chain of infection and protect them-
selves, their patients, and all other individuals.
STUDENT: Go to the workbook and complete

the assignment sheet for 14:4, Observing Standard
Precautions. Then return and continue with the
procedure.
FIGURE 14-18 All infectious wastes must be FIGURE 14-19 The health care worker must
placed in special infectious waste or biohazardous know the requirements for disposal of waste materi-
material bags. als and dispose of wastes in the proper containers.
PROCEDURE 14:4
4. Name four instances when gloves must
Observing Standard be worn to observe standard precau-
Precautions tions. Put on a pair of disposable gloves.
Practice removing the gloves without
Equipment and Supplies contaminating the skin. With a gloved
hand, grasp the cuff of the glove on the
Disposable gloves, infectious waste bags, nee- opposite hand, handling only the out-
dle and syringe, sharps container, gown, masks, side of the glove (figure 14-20A). Pull the
protective eyewear, resuscitation devices glove down and turn it inside out while
NOTE: This procedure will help you removing it. Take care not to touch the
learn standard precautions. It is impor- skin with the gloved hand. Using the
tant for you to observe these precautions at ungloved hand, slip the fingers under
all times while working in the laboratory or the cuff of the glove on the opposite
clinical area. hand (figure 14-20B). Touching only the
inside of the glove and taking care not to
Procedure touch the skin, pull the glove down and
turn it inside out while removing it. Place
1. Assemble equipment. the gloves in an infectious waste con-
tainer. Wash your hands immediately.
2. Review the precautions in the informa-
tion section for Observing Standard Pre- 5. Practice putting on a gown. State when
cautions. Note points that are not clear, a gown is to be worn. To remove the
and ask your instructor for an explana- gown, touch only the inside. Fold the
tion. contaminated gown so the outside is
folded inward. Roll it into a bundle and
3. Practice handwashing according to Pro-
place it in an infectious waste container
cedure 14:3. Identify at least six times
if it is disposable, or in a bag for contam-
that hands must be washed according
inated linen if it is not disposable.
to standard precautions.
FIGURE 14-20A To remove the first glove, FIGURE 14-20B To remove the second
use a gloved hand to grasp the outside of the glove, slip the fingers of the ungloved hand
glove on the opposite hand. Pull the glove down inside the cuff of the glove. Touch only the inside
and turn it inside out while removing it. of the glove while pulling it down and turning it
inside out.
370 CHAPTER 14
PROCEDURE 14:4
CAUTION: If a gown is contaminated, remove your gloves, and wash your
gloves should be worn while removing hands.
the gown.
9. Practice handling an infectious waste
NOTE: Folding the gown and rolling it bag. Fold down the top edge of the bag to
prevents transmission of pathogens. form a cuff at the top of the bag. Wear
gloves to close the bag after contami-
6. Practice putting on a mask and protec-
nated wastes have been placed in it. Put
tive eyewear. To remove the mask, han-
your hands under the folded cuff (figure
dle it by the ties only. Clean and disinfect
14-21A) and gently expel excess air from
protective eyewear after use.
the bag. Twist the top of the bag shut and
7. Practice proper disposal of sharps. fold down the top edges to seal the bag.
Uncap a needle attached to a syringe, Secure the fold with tape or a tie accord-
taking care not to stick yourself with the ing to agency policy (figure 14-21B).
needle. Place the entire needle and
10. Examine mouthpieces and resuscita-
syringe in a sharps container. State the
tion devices that can be used in place of
rules regarding disposal of the sharps
mouth-to-mouth resuscitation. You will
container.
be taught to use these devices when you
8. Spill a small amount of water on a coun- learn cardiopulmonary resuscitation
ter. Pretend that it is blood. Put on gloves (CPR).
and use disposable cloths or gauze to
11. Discuss the following situations with
wipe up the spill. Put the contaminated
another student and determine which
cloths or gauze in an infectious waste
standard precautions should be ob-
bag. Use clean disposable cloths or
served:
gauze to wipe the area thoroughly with
a disinfectant agent. Put the cloths or • A patient has an open sore on the skin
gauze in the infectious waste bag, and pus is seeping from the area. You
are going to bathe the patient.
• You are cleaning a tray of instruments
that contains a disposable surgical
blade and needle with syringe.
FIGURE 14-21A To close an infectious waste FIGURE 14-21B After folding down the top
bag, wear gloves and place your hands under edge of the infectious waste bag, tie or tape it
the cuff to gently expel excess air. securely.
PROCEDURE 14:4
• A tube of blood drops to the floor and
breaks, spilling the blood on the floor.
• Drainage from dressings on an
infected wound has soiled the linen
Practice
on the bed you are changing. evaluation sheet for 14:4, Observing
• You work in a dental office and are Standard Precautions. When you
assisting a dentist while a tooth is believe you have mastered this skill,
being extracted (removed). sign the sheet and give it to your
instructor for further action.
12. Replace all equipment used.

listed on the evaluation sheet, your
instructor will grade your performance.
and it will destroy all microorganisms, both

14:5 Information pathogenic and nonpathogenic, including spores
and viruses.
Sterilizing with an Autoclave Autoclaves are available in various sizes and
Sterilization of instruments and equipment is types. Offices and health clinics usually have
essential in preventing the spread of infection. In smaller units, and hospitals or surgical areas have
any of the health fields, you may be responsible large floor model units. A pressure cooker can be
for proper sterilization. The following basic prin- used in home situations.
ciples relate to sterilization methods. The auto- Before any equipment or supplies are steril-
clave is the safest, most efficient sterilization ized in an autoclave, they must be prepared prop-
method. erly. All items must be washed thoroughly and
An autoclave is a piece of equipment that then rinsed. Oily substances can often be removed
uses steam under pressure or gas to sterilize with alcohol or ether. Any residue left on articles
equipment and supplies (figure 14-22). It is the will tend to bake and stick to the article during
most efficient method of sterilizing most articles, the autoclaving process.
Items that are to remain sterile must be
wrapped before they are autoclaved. A wide vari-
ety of wraps are available. The wrap must be a
material that will allow for the penetration of
steam during the autoclaving process. Samples of
wraps include muslin, autoclave paper, special
plastic or paper bags, and autoclave containers
(figure 14-23).
Autoclave indicators are used to ensure that
articles have been sterilized (figure 14-24). Exam-
ples of indicators include autoclave tape, sensi-
tivity marks on bags or wraps, and indicator
capsules. The indicator is usually placed on or
near the article when the article is put into the
autoclave. Indicators can also be placed in the
center of a package, such as a tray of instruments,
FIGURE 14-22 An autoclave uses steam under to show that sterilization of the entire package
pressure to sterilize items. has occurred. The indicator will change appear-
372 CHAPTER 14
the top of the chamber and moves downward. As

it moves down, it pushes cool, dry air out of the
bottom of the chamber. Therefore, materials
must be placed so the steam can penetrate along
the natural planes between the packages of arti-
cles in the autoclave. Place the articles in such a
way that there is space between all pieces. Pack-
ages should be placed on the sides, not flat. Jars,
basins, and cans should be placed on their sides,
not flat, so that steam can enter and air can flow
out. No articles should come in contact with the
sides, top, or door of the autoclave.
The length of time and amount of pressure
required to sterilize different items varies (figure
14-25). It is important to check the directions that
come with the autoclave. Because different types
of articles require different times and pressures,
it is important to separate loads so that all articles
sterilized at one time require the same time and
pressure. For example, rubber tubings usually
require a relatively short period of time and can
FIGURE 14-23 Special plastic or paper autoclave Articles Time at

bags can be used to sterilize instruments. 250° to 254°F
(121° to 123°C)
Glassware: empty, inverted 15 minutes

Instruments: metal in covered or
open, padded or unpadded tray
Needles, unwrapped
Syringes: unassembled, unwrapped
Instruments, metal combined with
other materials in covered and/or
padded tray
Instruments wrapped in double- 20 minutes
thickness muslin
Flasked solutions, 75–250 mL
Needles, individually packaged in
glass tubes or paper
FIGURE 14-24 Autoclave indicators change color Syringes: unassembled, individually 30 minutes
to show that sterilization has occurred. The strips
packed in muslin or paper
below each package show how the indicators
Dressings wrapped in paper or
looked before sterilization.
muslin (small packs only)
ance during the autoclaving process because of Flasked solutions, 500–1,000 mL
time and temperature, which leads to steriliza- Sutures: silk, cotton, or nylon;
tion. Learn how to recognize that an article is wrapped in paper or muslin
sterile by reading the directions provided with Treatment trays wrapped in
indicators. muslin or paper
The autoclave must be loaded correctly for all FIGURE 14-25 The length of time required to
parts of an article to be sterilized. Steam builds at sterilize different items varies.
be damaged by long exposure. Certain instru- for sterilizing instruments that may corrode, such
ments and needles require a longer period of time as knife blades, or items that would be destroyed
to ensure sterilization; therefore, items of this by the moisture in steam sterilization, such as
type should not be sterilized in the same load as powders. Dry heat should never be used on soft
are rubber tubings. rubber goods because the heat will destroy the
Wet surfaces permit rapid infiltration of rubber. Some types of plastic will also melt in dry
organisms, so it is important that all items are heat. An oven can be used for dry-heat steriliza-
thoroughly dry before being removed from the tion in home situations.
autoclave. The length of time for drying varies. Procedures 14:5A and 14:5B describe wrap-
Follow the manufacturer’s instructions. ping articles for autoclaving and autoclaving
Sterilized items must be stored in clean, dust- techniques. These procedures vary in different
proof areas. Items usually remain sterile for 30 agencies and areas, but the same principles apply.
days after autoclaving. However, if the wraps In some facilities, many supplies are purchased
loosen or tear, if they become wet, or if any chance as sterile, disposable items; needles and syringes
of contamination occurs, the items should be are purchased in sterilized wraps, used once, and
rewrapped and autoclaved again. then destroyed. In other facilities, however, spe-
NOTE: At the end of the 30-day sterile period— cial treatment trays are sterilized and used more
providing that the wrap has not loosened, been than one time.
torn, or gotten wet—remove the old autoclave It is important that you follow the directions
tape from the package, replace with a new, dated specific to the autoclave with which you are
tape, and resterilize according to correct proce- working as well as the agency policy for sterile
dure. supplies. Careless autoclaving permits the trans-
Some autoclaves are equipped with a special mission of disease-producing organisms. Infec-
door that allows the autoclave to be used as a dry- tion control is everyone’s responsibility.
heat sterilizer. Dry heat involves the use of a high
temperature for a long period of time. The tem- STUDENT: Go to the workbook and complete
perature is usually a minimum of 320–350°F the assignment sheet for 14:5, Sterilizing with an
(160–177°C). The minimum time is usually 60 Autoclave. Then return and continue with the pro-
minutes. Dry-heat sterilization is a good method cedures.
PROCEDURE 14:5A
CAUTION: If the items to be autoclaved
Wrapping Items are contaminated with blood, body flu-
for Autoclaving ids, or tissues, gloves must be worn
while cleaning the items.
Equipment and Supplies 3. Sanitize the items to be sterilized. Instru-
ments, bowls, and similar items should
Items to wrap: instrument, towel, bowl; auto-
be cleaned thoroughly in soapy water
clave wrap: paper, muslin, plastic or paper
(figure 14-26). Rinse the items well in
bag; autoclave tape or indicator; disposable
cool water to remove any soapy residue.
or utility gloves; pen or autoclave marker;
Then rinse well with hot water. Dry the
masking tape (if autoclave tape is not used)
items with a towel. After the items are
sanitized and dry, remove the gloves and
Procedure wash hands.
1. Assemble equipment. NOTE: If stubborn stains are present, it
may be necessary to soak the items.
2. Wash hands. Put on gloves.
374 CHAPTER 14
PROCEDURE 14:5A
end until a compact package is formed
(figure 14-27A). All folds should be the
same size. Fold back one corner on the
top fold (figure 14-27B). This provides a
piece to grab when opening the linen.
NOTE: Fanfolding linens allows for easy
handling after sterilization.
5. Select the correct wrap for the item.
Make sure the wrap is large enough to
enclose the item to be wrapped.
NOTE: Double-thickness muslin, dis-
posable paper wraps, and plastic or
paper bags are the most common
wraps.
6. With the wrap positioned at a diagonal
FIGURE 14-26 Wear gloves to scrub instru- angle and one corner pointing toward
ments thoroughly with soapy water. you, place the item to be sterilized in the
center of the wrap.
NOTE: Check the teeth on serrated
NOTE: Make sure that hinged instru-
(notched like a saw) instruments. Scrub
ments are open so the steam can steril-
with a brush as necessary.
ize all edges.
4. To prepare linen for wrapping, check
7. Fold up the bottom corner to the center
first to make sure it is clean and dry. Fold
(figure 14-28A). Double back a small
the linen in half lengthwise. If it is very
corner (figure 14-28B).
wide, fold lengthwise again. Fanfold or
accordion pleat the linen from end to 8. Fold a side corner over to the center.
Make sure the edges are sealed and that
there are no air pockets. Bring back a
small corner (figure 14-28C).
FIGURE 14-27A Fanfold clean, dry linen so FIGURE 14-27B Fold back one corner on the
all the folds are the same size. top fold of the linen.
PROCEDURE 14:5A
FIGURE 14-28A Place the FIGURE 14-28B Turn a small FIGURE 14-28C Fold in one
instrument in the center of the corner back to form a tab. side and fold back a tab.
wrap. Fold the bottom corner in
to the center.
FIGURE 14-28D Fold in the FIGURE 14-28E Bring the FIGURE 14-28F Secure the
opposite side and fold back a final corner up and over the top package with autoclave tape.
tab. of the pack and tuck it in, leaving Label it with the date, contents,
a small corner exposed. and your initials.
376 CHAPTER 14
PROCEDURE 14:5A
CAUTION: Any open areas at corners 13. Check the package. It should be firm
will allow pathogens to enter. enough for handling but loose enough
for proper circulation of steam.
9. Fold in the other side corner. Again,
watch for and avoid open edges. Bring 14. To use a plastic or paper autoclave bag
back a small corner (figure 14-28D). (refer to figure 14-23), select or cut the
correct size for the item to be sterilized.
10. Bring the final corner up and over the
Place the clean item inside the bag.
top of the package. Check the two edges
Double fold the open end(s) and tape or
to be sure they are sealed and tight. Tuck
secure with autoclave tape. Check the
this under the pocket created by the
package to make sure it is secure.
previous folds. Leave a small corner
exposed so it can be used when unwrap- NOTE: In some agencies, the ends are
ping the package (figure 14-28E). sealed with heat prior to autoclaving.
NOTE: This is frequently called an “enve- NOTE: If the bag has an autoclave indi-
lope” wrap, because the final corner is cator, regular masking tape can be used
tucked into the wrap similar to the way to seal the ends.
the flap is tucked into an envelope.
15. Replace all equipment used.
11. Secure with autoclave or pressure-
16. Wash hands.
sensitive indicator tape.
NOTE: If regular masking tape is used,
attach an autoclave indicator to reflect
when contents are sterilized.
12. Label the package by marking the
Practice
tape with the date and contents (figure
evaluation sheet for 14:5A,
14-28F). Some health care agencies may
require you to initial the label. Wrapping Items for Autoclaving, to
practice this procedure. When you
NOTE: For certain items, the type or size believe you have mastered this skill,
of item should be noted, for example, sign the sheet and give it to your
curved hemostat or mosquito hemostat, instructor for further action.
hand towel or bath towel, small bowl or
large bowl.
NOTE: Contents will not be sterile after Final Checkpoint Using the criteria
30 days, so the date of sterilization must listed on the evaluation sheet, your
be noted on the package. instructor will grade your performance.
PROCEDURE 14:5B
or to the level indicated on the auto-
Loading and Operating clave.
an Autoclave NOTE: Distilled water prevents the col-
NOTE: Follow the operating instructions for lection of mineral deposits and prolongs
your autoclave. The basic principles of load- the life and effectiveness of the auto-
ing apply to all autoclaves. Basic controls for clave.
one autoclave are shown in figure 14-29.
5. Check the pressure gauge to make sure
it is at zero.
CAUTION: Never open the door unless
Autoclave, distilled water, small pitcher or the pressure is zero.
measuring cup, items wrapped or prepared
for autoclaving, time chart for autoclave, 14:5 6. Open the safety door by following the
Information section manufacturer’s instructions. Some door
handles require an upward and inward
Procedure pressure; others require a side-pressure
technique.
Review the Information section for 14:5, Steril-
7. Load the autoclave. Make sure all arti-
izing with an Autoclave. Then proceed with
cles have been prepared correctly. Check
the following activities. You should read
for autoclave indicators, secure wraps,
through the procedure first, checking against
and correct labels. Separate loads so all
the diagram. Then practice with an autoclave.
items require the same time, tempera-
1. Assemble equipment. ture, and pressure. Place packages on
their sides. Place bowls or basins on
2. Wash and dry hands thoroughly.
their sides so air and steam can flow in
3. Check the three-prong plug and the and out of the container (figure 14-30).
electrical cord. If either is damaged or Make sure there is space between the
prongs are missing, do not use the auto- packages so the steam can circulate.
clave. If no problems are present, plug
NOTE: Check to make sure no large
the cord into a wall outlet.
packages block the steam flow to smaller
4. Use distilled water to fill the reservoir to packages. Place large packages on the
within 2 1/2 inches below the opening bottom.
(A) (B)
FIGURE 14-30 Bowls or basins should be
placed on their sides in the autoclave so air and
FIGURE 14-29 Autoclave control valves vary, steam can flow in and out of the container: (A)
but most contain the same basic controls. incorrect placement; (B) correct placement.
378 CHAPTER 14
PROCEDURE 14:5B
CAUTION: Make sure no item comes in 17. When the required time has passed, set
contact with the sides, top, or door of the controls so the autoclave will vent
the autoclave chamber. the steam from the chamber.
8. Follow the instructions for filling the 18. Put on safety glasses.
chamber with the correct amount of CAUTION: Never open the door without
water. Most autoclaves have a “Fill” set- glasses. The escaping steam can burn
ting on the control. Allow water to enter the eyes.
the chamber until the water covers the 19. Check the pressure and temperature
fill plate inside the chamber. gauges. When the pressure gauge is at
9. When the correct amount of water is in zero, and the temperature gauge is at or
the chamber, follow the instructions for below 212°F, open the door about 1/2 to
stopping the flow of water. In many 1 inch to permit thorough drying of con-
autoclaves, turning the control valve to tents.
“Sterilize” stops the flow of water from CAUTION: Do not open the door until
the reservoir. pressure is zero.
10. Check the load in the chamber to be NOTE: Most autoclaves have a safety
sure it is properly spaced. The chamber lock on the door that does not release
can also be loaded at this point, if this until the pressure is at zero.
has not been done previously. 20. After the autoclaved items are com-
11. Close and lock the door. pletely dry, remove and store them in a
CAUTION: Be sure the door is securely dry, dust-free area.
locked; check by pulling slightly. CAUTION: Handle supplies and equip-
12. Read the time chart for the specific time ment carefully. They may be hot.
and temperature required for steriliza- 21. If there are additional loads to run, leave
tion of items that were placed in the the main valve in the vent position. This
autoclave. will keep the autoclave ready for imme-
13. After referring to the chart provided with diate use.
the autoclave or reviewing figure 14-25, 22. If this is the final load, turn the auto-
set the control valves to allow the tem- clave off. Unplug the cord from the wall
perature and pressure to increase in the outlet; do not pull on the cord.
autoclave. NOTE: The autoclave must be cleaned
14. When the desired temperature (usually on a regular basis. Follow manufactur-
250–254°F or 121–123°C) and pressure er’s instructions.
(usually 15 pounds) have been reached, 23. Replace all equipment used.
set the controls to maintain the desired 24. Wash hands.
temperature during the sterilization
process. Follow the manufacturer’s
instructions.
15. Based on the information in the time
Practice
chart, set the timer to the correct time. Go to the workbook and use the
evaluation sheet for 14:5B, Loading
NOTE: Many autoclaves require you to and Operating an Autoclave, to
rotate the timer past 10 (minutes) before
setting the time.
believe you have mastered this skill,
16. Check the pressure and temperature sign the sheet and give it to your
gauges at intervals to make sure they instructor for further action.
remain as originally set.
NOTE: Most autoclaves automatically Final Checkpoint Using the criteria
shut off when pressure reaches 35 listed on the evaluation sheet, your
pounds. instructor will grade your performance.
also specify the recommended time for the most

14:6 Information thorough disinfection.
Chemical solutions can cause rust to form on
Using Chemicals for Disinfection certain instruments, so antirust tablets or solu-
Many health fields require the use of chemicals tions are frequently added to the chemicals.
for aseptic control. Certain points that must be Again, it is important to read the directions pro-
observed while using the chemicals are discussed vided with the tablets or solution. If improperly
in the following section. used, antirust substances may cause a chemical
Chemicals are frequently used for aseptic reaction with a solution and reduce the effective-
control. Many chemicals do not kill spores and ness of the chemical disinfectant.
viruses; therefore, chemicals are not a method of The container used for chemical disinfection
sterilization. Because sterilization does not occur, must be large enough to accommodate the items.
chemical disinfection is the appropriate term In addition, the items should be separate so each
(rather than cold sterilization, a term sometimes one will come in contact with the chemical. A
used). A few chemicals will kill spores and viruses, tight-fitting lid must be placed on the container
but these chemicals frequently require that while the articles are in the solution to prevent
instruments be submerged in the chemical for 10 evaporation that could affect the strength of the
or more hours. It is essential to read an entire solution. The lid also decreases the chance of
label to determine the effectiveness of the prod- dust and airborne particles from falling into the
uct before using any chemical. solution.
Chemicals are used to disinfect instruments The chemical disinfectant must completely
that do not penetrate body tissue. Many dental cover the article. This is the only way to be sure
instruments, percussion hammers, scissors, and that all parts of the article will be disinfected.
similar items are examples. In addition, chemi- Before removing items from solutions, health
cals are used to disinfect thermometers and other workers must wash their hands. Sterile gloves or
items that would be destroyed by the high heat sterile pick-ups or transfer forceps may be used
used in the autoclave. to remove the instruments from the solution. The
Proper cleaning of all instruments or articles items should be rinsed with sterile water to
is essential. Particles or debris on items may con- remove any remaining chemical solution. After
taminate the chemicals and reduce their effec- rinsing, the instruments are placed on a sterile or
tiveness. In addition, all items must be rinsed clean towel to dry, and then stored in a drawer or
thoroughly because the presence of soap can also dust-free closet.
reduce the effectiveness of chemicals. The arti- Solutions must be changed frequently. Some
cles must be dry before being placed in the disin- solutions can be used over a period of time, but
fectant to keep the chemical at its most effective others must be discarded after one use. Follow
strength. the manufacturer’s instructions. However, any
Some chemical solutions used as disinfec- time contamination occurs or dirt is present in
tants are 90-percent isopropyl alcohol, formalde- the solution, discard it. A fresh solution must be
hyde–alcohol, 2-percent phenolic germicide, used.
10-percent bleach (sodium hypochlorite) solu-
tion, glutaraldehyde, iodophor, Lysol, Cidex, and STUDENT: Go to the Workbook and complete
benzalkonium (zephiran). The manufacturer’s the assignment sheet for 14:6, Using Chemicals for
directions should be read completely before Disinfection. Then return and continue with the
using any solution. Some solutions must be procedure.
diluted or mixed before use. The directions will
380 CHAPTER 14
PROCEDURE 14:6
so the solution can flow between the
Using Chemicals for surfaces.
Disinfection 7. Carefully read label instructions about
the chemical solution. Some solutions
Equipment and Supplies must be diluted. Check the manufactur-
er’s recommended soaking time.
Chemicals, container with tight-fitting lid,
basin, soap, water, instruments, brush, sterile CAUTION: Reread instructions to be
pick-ups or transfer forceps, sterile towel, sure solution is safe to use on instru-
sterile gloves, eye protection, disposable ments.
gloves
NOTE: An antirust substance must be
added to some solutions.
Procedure
8. Pour solution into the container slowly
1. Assemble equipment. to avoid splashing. Make sure that all
instruments are covered (figure 14-31).
2. Wash hands. Put on disposable or heavy- Close the lid of the container.
duty utility gloves and eye protection.
NOTE: Read label three times: before
NOTE: Wear gloves if any of the instru- pouring, while pouring, and after pour-
ments or equipment are contaminated ing.
with blood or body fluids. Wear eye pro-
tection if there is any chance splashing CAUTION: Avoid splashing the chemi-
will occur. cal on your skin. Improper handling of
chemicals may cause burns and/or inju-
3. Wash all instruments or equipment ries.
thoroughly. Use warm soapy water. Use
the brush on serrated edges of instru- 9. Remove gloves. Wash hands.
ments. 10. Leave the instruments in the solution
NOTE: All tissue and debris must be for the length of time recommended by
removed from the instrument or item or the manufacturer.
it will not be disinfected.
4. Rinse in cool water to remove soapy res-
idue. Then rinse well with hot water. Dry
all instruments or equipment thor-
oughly.
NOTE: Water on the instruments or
equipment will dilute the chemical dis-
infectant.
5. Check container. Make sure lid fits
securely.
NOTE: A loose cover will permit
entrance of pathogens and/or evapora-
tion of the chemical solution.
6. Place instruments in the container. FIGURE 14-31 Pour the chemical disinfectant
Make sure there is a space between into the container until all instruments are
instruments. Leave hinged edges open covered with solution.
PROCEDURE 14:6
NOTE: Twenty to 30 minutes is the usual 12. Replace all equipment used.
soaking time.
CAUTION: If the disinfectant solution
NOTE: If the solution requires a long can be used again, label the container
period (for example, 10–12 hours) for with the name of the disinfectant, date,
disinfecting, label the container with and number of days it can be used
the date and time the process began, according to manufacturer’s instruc-
ending date and time, and your initials. tions. When solutions cannot be reused,
dispose of the solution according to
11. When instruments have soaked the cor-
manufacturer’s instructions.
rect amount of time, use sterile gloves or
sterile pick-ups or transfer forceps to 13. Remove gloves. Wash hands.
remove the instruments from the solu-
tion. Hold the instruments over a sink or
basin and pour sterile water over them
to rinse them thoroughly. Place them on Practice
a sterile towel to dry. A second sterile Go to the workbook and use the
towel is sometimes used to dry the evaluation sheet for 14:6, Using
instruments or to cover the instruments Chemicals for Disinfection, to
while they are drying. Store the instru- practice this procedure. When you
ments in special drawers, containers, or believe you have mastered this skill,
dust-free closets. sign the sheet and give it to your
NOTE: Some contamination occurs instructor for further action.
when instruments are exposed to the
air. In some cases, such as with external Final Checkpoint Using the criteria
instruments, this minimal contamina- listed on the evaluation sheet, your
tion will not affect usage. instructor will grade your performance.
cles. If sterilization is desired, other methods

14:7 Information must be used after the ultrasonic cleaning.
Only ultrasonic solutions should be used in
Cleaning with an Ultrasonic Unit the unit. Different solutions are available for dif-
Ultrasonic units are used in many dental and ferent materials. A general, all-purpose cleaning
medical offices and other health agencies to solution is usually used in the permanent tank
remove dirt, debris, blood, saliva, and tissue from and to clean many items. There are other specific
a large variety of instruments prior to sterilizing solutions for alginate, plaster and stone removal,
them. Ultrasonic cleaning uses sound waves to and tartar removal. The solution chart provided
clean. When the ultrasonic unit is turned on, the with the ultrasonic unit will state which solution
sound waves produce millions of microscopic should be used. It is important to read labels care-
bubbles in a cleaning solution. When the bubbles fully before using any solutions. Some solutions
strike the items being cleaned, they explode, a must be diluted before use. Some can be used
process known as cavitation, and drive the only on specific materials. All solutions are toxic.
cleaning solution onto the article. Accumulated They can also cause skin irritation, so contact
dirt and residue are easily and gently removed with the skin and eyes should be avoided. Solu-
from the article. tions should be discarded when they become
Ultrasonic cleaning is not sterilization cloudy or contaminated, or if cleaning results are
because spores and viruses remain on the arti- poor.
382 CHAPTER 14
The permanent tank of the ultrasonic unit Many different items can be cleaned in an
(figure 14-32) must contain a solution at all times. ultrasonic unit. Examples include instruments,
A general, all-purpose cleaning solution is used impression trays, glass products, and most jew-
most of the time. Glass beakers or auxiliary pans elry. The ultrasonic unit should not be used on
or baskets can then be placed in the permanent jewelry with pearls or pasted stones. The sound
tank. The items to be cleaned and the proper waves can destroy the pearls or the paste holding
cleaning solution are then put in the beakers or the stones. Prior to cleaning, most of the dirt or
pans. The bottoms of the beakers or pans must particles should be brushed off the items being
always be positioned below the level of the solu- cleaned. It is better to clean a few articles at a
tion present in the permanent tank. In this way, time and avoid overloading the unit. If items are
cavitation can be transmitted from the main tank close together, the process of cavitation is poor
and through the solution to the items being because the bubbles cannot strike all parts of the
cleaned in the beakers or pans. The ultrasonic items being cleaned.
unit should never be operated without solutions The glass beakers used in the ultrasonic unit
in both containers. In addition, the items being are made of a type of glass that allows the passage
cleaned must be submerged in the cleaning solu- of sound waves. After continual use, the sound
tion. waves etch the bottom of the beakers. A white,
opaque coating forms. The beakers must be dis-
carded and replaced when this occurs. After each
use, the beakers should be washed with soap and
Permanent tank Pilot Timer Cleaning water and rinsed thoroughly to remove any soapy
(for beakers and light solution
auxiliary pan) residue. They must be dry before being filled with
Lid solution because water in the beaker can dilute
the solution.
The permanent tank of the unit must be
drained and cleaned at intervals based on tank
use or appearance of the solution in the tank. A
drain valve on the side of the tank is opened to
allow the solution to drain. The tank is then wiped
with a damp cloth or disinfectant. Another damp
cloth or disinfectant is used to wipe off the out-
side of the unit. The unit should never be sub-
merged in water to clean it. After cleaning, a fresh
solution should be placed in the permanent
tank.
The manufacturer’s instructions must be read
carefully before using any ultrasonic unit. Most
Drain manufacturers provide cleaning charts that state
Auxiliary the type of solution and time required for a vari-
pan with ety of cleaning problems. Each time an item is
solution cleaned in an ultrasonic unit, the chart should be
Beaker used to determine the correct cleaning solution
with and time required.
solution
Positioning
cover for STUDENT: Go to the workbook and complete
beakers the assignment sheet for 14:7, Cleaning with an
FIGURE 14-32 Parts of an ultrasonic cleaning Ultrasonic Unit. Then return and continue with
unit. the procedure.
PROCEDURE 14:7
4. Check the permanent tank to be sure it
Cleaning with an has enough cleaning solution. An all-
Ultrasonic Unit purpose cleaning solution is usually
used in this tank.
Equipment and Supplies CAUTION: Never run the unit without
solution in the permanent tank.
Ultrasonic unit, permanent tank with solu-
tion, beakers, auxiliary pan or basket with NOTE: Many solutions must be diluted
covers, beaker bands, cleaning solutions, before use; if new solution is needed,
transfer forceps or pick-ups, paper towels, read the instructions on the bottle.
gloves, brush, soap, water for rinsing, articles
5. Pour the proper cleaning solution into
for cleaning, solution chart
the auxiliary pan or beakers.
Procedure NOTE: Use the cleaning chart to deter-

mine which solution to use.
1. Assemble all equipment. CAUTION: Read label before using.
2. Wash hands. Put on gloves if any CAUTION: Handle solutions carefully.
items are contaminated with Avoid contact with skin and eyes.
blood, body fluids, secretions, or excre-
tions. 6. Place the beakers, basket, or auxiliary
pan into the permanent tank (figures
NOTE: Use heavy-duty utility gloves if 14-33A and B). Use beaker positioning
instruments are sharp. covers and beaker bands. Beaker bands
3. Use a brush and soap and water to are large bands that circle the beakers to
remove any large particles of dirt from hold them in position and keep them
articles to be cleaned. Rinse articles from hitting the bottom of the perma-
thoroughly. Dry items. nent tank.
NOTE: Rinsing is important because
soap may interact with the cleaning
solution.
FIGURE 14-33A The auxiliary basket can be FIGURE 14-33B Glass beakers can be used
used to clean larger items in an ultrasonic unit. to clean smaller items in an ultrasonic unit.
384 CHAPTER 14
PROCEDURE 14:7
7. Check to be sure that the bottoms of the 13. Periodically change solutions in the per-
beakers, basket, or pan are below the manent tank and auxiliary containers.
level of solution in the permanent tank. Do this when solutions become cloudy
or cleaning has not been effective. To
NOTE: For sonic waves to flow through
clean the permanent tank, place a con-
solutions in the beakers, basket, or pan,
tainer under the side drain to collect the
the two solution levels must overlap.
solution. Then open the valve and drain
8. Place articles to be cleaned in the bea- solution from the tank. Wash the inside
kers, basket, or pan. Be sure the solution with a damp cloth or disinfectant. To
completely covers the articles. Do not clean the auxiliary pans or beakers, dis-
get solution on your hands. card the solution. (It can be poured
NOTE: Remember that pearls or pasted down the sink, but allow water to run for
stones cannot be cleaned in an ultra- a time after disposing of the solution.)
sonic unit. Then wash the containers and rinse
thoroughly.
9. Turn the timer past 5 (minutes) and
then set the proper cleaning time. Use NOTE: If the bottoms of beakers are
the cleaning chart to determine the cor- etched and white, the beakers must be
rect amount of time required for the discarded and replaced.
items. Most articles are cleaned in 2–5 14. Clean and replace all equipment used.
minutes. Make sure all beakers are covered with
10. Check that the unit is working. You lids.
should see a series of bubbles in both 15. Wash hands.
solutions. This is called cavitation.
CAUTION: Do not get too close. Solu-
tion can spray into your face and eyes.
Use beaker lids to prevent spray.
11. When the timer stops, cleaning is com-
Practice
plete. Use transfer forceps or pick-ups evaluation sheet for 14:7, Cleaning
to lift articles from the basket, pan, or
with an Ultrasonic Unit, to practice
beakers. Place the articles on paper tow-
this procedure. When you believe
els. Then rinse articles thoroughly under
you have mastered this skill, sign
running water.
the sheet and give it to your
CAUTION: Avoid contact with skin. instructor for further action.
Solutions are toxic.
12. Allow articles to air-dry or dry them with
paper towels. Inspect the articles for Final Checkpoint Using the criteria
cleanliness. If they are not clean, repeat listed on the evaluation sheet, your
the process. instructor will grade your performance.
Organisms and pathogens travel quickly

14:8 INFORMATION through a wet surface, so the sterile field must be
kept dry. If a sterile towel or article gets wet, con-
Using Sterile Techniques tamination has occurred. It is very important to
Many procedures require the use of sterile tech- use care when pouring solutions into sterile
niques to protect the patient from further infec- bowls or using solutions around a sterile field.
tion. Surgical asepsis refers to procedures that Various techniques can be used to remove
keep an object or area free from living organisms. articles from sterile wraps, depending on the arti-
The main facts are presented here. cle being unwrapped. Some common techniques
Sterile means “free from all organisms,” are the drop, mitten, and transfer-forceps tech-
including spores and viruses. Contaminated niques:
means that organisms and pathogens are pres-
♦ Drop technique: This technique is used for
ent. While working with sterile supplies, it is
gauze pads, dressings, and small items. The
important that correct techniques be followed to
wrapper is partially opened and then held
maintain sterility and avoid contamination. It is
upside down over the sterile field. The item
also important that you are able to recognize
drops out of the wrapper and onto the sterile
sterile surfaces and contaminated surfaces.
field (figure 14-34A). It is important to keep
A clean, uncluttered working area is required
fingers back so the article does not touch the
when working with sterile supplies. A sterile
skin as it falls out of the wrapper. It is also
object must never touch a nonsterile object. If
important to avoid touching the inside of the
other objects are in the way, it is easy to contami-
wrapper.
nate sterile articles. If sterile articles touch the
skin or any part of your clothing, they are no lon- ♦ Mitten technique: This technique is used for
ger sterile. Because any area below the waist is bowls, drapes, linen, and other similar items.
considered contaminated, sterile articles must The wrapper is opened and its loose ends are
be held away from and in front of the body and grasped around the wrist with the opposite
above the waist. hand (figure 14-34B). In this way, a mitten is
Once a sterile field has been set up (for formed around the hand that is still holding
example, a sterile towel has been placed on a the item (for example, a bowl). With the mit-
tray), never reach across the top of the field. ten hand, the item can be placed on the sterile
Microorganisms can drop from your arm or tray.
clothing and contaminate the field. Always reach ♦ Transfer forceps: These are used for cotton
in from either side to place additional articles on balls, small items, or articles that cannot be
the field. Keep the sterile field in constant view. removed by the drop or mitten techniques.
Never turn your back to a sterile field. Avoid Either sterile gloves or sterile transfer forceps
coughing, sneezing, or talking over the sterile (pick-ups) are used. Sterile transfer forceps or
field because airborne particles can fall on the pick-ups are removed from their container of
field and contaminate it. disinfectant solution and used to grasp the
The 2-inch border around the sterile field
(towel-covered tray) is considered contaminated.
Therefore, 2 inches around the outside of the field
must not be used when sterile articles are placed
on the sterile field.
All sterile items must be checked carefully
before they are used. If the item was autoclaved
and dated, most health care facilities believe the
date should not be more than 30 days from auto-
claving. Follow agency guidelines for time limits.
If tears or stains are present on the package, the
item should not be used because it could be con-
taminated. If there are any signs of moisture on
the package, it has been contaminated and FIGURE 14-34A Sterile items can be dropped
should not be used. from the wrapper onto the sterile field.
386 CHAPTER 14
FIGURE 14-34B By using the wrap as a mitten,

sterile supplies can be placed on a sterile field. FIGURE 14-34C Sterile transfer forceps or pick-
ups can be used to grasp sterile items and place
article from the opened package. The item is them on a sterile field.
removed from the opened, sterile wrap and
tant to hold the hands away from the body and
placed on the sterile field (figure 14-34C). The
above the waist to avoid contamination. Handle
transfer forceps must be pointed in a down-
only sterile objects while wearing sterile gloves.
ward direction. If they are pointed upward,
If at any time during a procedure there is any
the solution will flow back to the handle,
suspicion that you have contaminated any article,
become contaminated, and return to contam-
start over. Never take a chance on using contami-
inate the sterile tips when they are being used
nated equipment or supplies.
to pick up items. In addition, care must be
A wide variety of commercially prepared ster-
taken not to touch the sides or rim of the for-
ile supplies is available. Packaged units are often
ceps container while removing or inserting
set up for special procedures, such as changing
the transfer forceps. Also, the transfer forceps
dressings. Many agencies use these units instead
must be shaken gently to get rid of excess dis-
of setting up special trays. Observe all sterile prin-
infectant solution before they are used.
ciples while using these units and read any direc-
Make sure the sterile tray is open and you are tions provided with the units.
ready to do the sterile procedure before putting
the sterile gloves on your hands. Sterile gloves are STUDENT: Go to the workbook and complete
considered sterile on the outside and contami- the assignment sheet for 14:8, Using Sterile Tech-
nated on the inside (side against the skin). Once niques. Then return and continue with the proce-
they have been placed on the hands, it is impor- dures.
PROCEDURE 14:8A
Opening Sterile Procedure
Packages 1. Assemble equipment.
2. Wash hands.
3. Take equipment to the area where it will
Sterile package of equipment or supplies, a be used. Check the autoclave indicator
table or other flat surface, sterile field (tray and date on the package. Check the
with sterile towel) package for stains, tears, moisture, or
PROCEDURE 14:8A
evidence of contamination. Do not use 8. With one hand, raise a side flap and pull
the package if there is any evidence of laterally (sideways) away from the pack-
contamination. age (figure 14-35B).
NOTE: Contents are not considered CAUTION: Do not touch the inside of
sterile if 30 days have elapsed since the wrapper at any time.
autoclaving.
9. With the opposite hand, open the other
4. Pick up the package with the tab or side flap by pulling the tab to the side
sealed edge pointing toward you. If the (figure 14-35C).
item is small, it can be held in the hand
NOTE: Always reach in from the side.
while being unwrapped. If it is large,
Never reach across the top of the sterile
place it on a table or other flat surface.
field or across any opened edges.
5. Loosen the wrapper fastener (usually
10. Open the proximal (closest) flap by lift-
tape).
ing the flap up and toward you. Then
6. Check to be sure the package is away drop it over the front of your hand (or
from your body. If it is on a table, make the table) (figure 14-35D).
sure it is not close to other objects.
CAUTION: Be careful not to touch the
NOTE: Avoid possible contamination by inside of the package or the contents of
keeping sterile supplies away from other the package.
objects.
11. Transfer the contents of the sterile pack-
7. Open the distal (furthest) flap of the age using one of the following tech-
wrapper by grasping the outside of the niques:
wrapper and pulling it away from you
a. Drop: Separate the ends of the wrap
(figure 14-35A).
and pull apart gently (figure 14-36).
CAUTION: Do not reach across the top Avoid touching the inside of the wrap.
of the package. Reach around the pack- Secure the loose ends of the wrap and
age to open it. hold the package upside down over
FIGURE 14-35A To open a sterile package, FIGURE 14-35B Open one side by pulling
open the top flap away from you, handling only the wrap out to the side.
the outside of the wrap.
388 CHAPTER 14
PROCEDURE 14:8A
FIGURE 14-35C Open the opposite side by FIGURE 14-35D Open the side nearest to
pulling the wrap out to the opposite side. you by pulling back on the wrap.
the sterile field. Allow the contents to securely around your wrist. This can
drop onto the sterile tray (refer to fig- be compared to making a mitten of
ure 14-34A). the wrapper (with the sterile equip-
ment on the outside of the mitten).
b. Mitten: Grasp the contents securely
Place the item on the sterile tray or
by holding on to the outside of the
hand it to someone who is wearing
wrapper as you unwrap it. With your
sterile gloves (refer to figure 14-34B).
free hand, gather the loose edges of
the wrapper together and hold them c. Transfer forceps: Remove forceps from
their sterile container, taking care not
to touch the side or rim of the con-
tainer with the forceps (figure 14-37).
Hold the forceps pointed downward.
Shake them gently to remove excess
disinfectant solution. Take care not to
touch anything with the forceps. Use
the forceps to grasp the item in the
package and then place the item on
the sterile tray.
NOTE: The method of transfer depends
on the sterile item being transferred.
NOTE: If at any time during the proce-
dure there is any suspicion that you
have contaminated any article, start
over. Never take a chance on using
equipment for a sterile procedure if
there is any possibility that the equip-
FIGURE 14-36 Separate the ends of the ment is contaminated.
wrap and pull the edges apart gently without
touching the contents. 12. Replace all equipment used.
13. Wash hands.
PROCEDURE 14:8A
Practice
evaluation sheet for 14:8A, Opening
Sterile Packages, to practice this
procedure. When you believe you
have mastered this skill, sign the
sheet and give it to your instructor
for further action.

FIGURE 14-37 Remove the transfer or pick-

up forceps without touching the sides or rim of
the container and point them in a downward
direction.
PROCEDURE 14:8B
3. Check the date and autoclave indicator
Preparing a Sterile for sterility. If more than 30 days have
Dressing Tray elapsed, use another package with a
more recent date. Put the unsterile pack-
Equipment and Supplies age aside for resterilization. Check the
package for stains, tears, moisture, or
Tray or Mayo stand, sterile towels, sterile evidence of contamination. Do not use
basin, sterile cotton balls or gauze sponges, the package if there is any evidence of
sterile dressings (different sizes), antiseptic contamination.
solution, forceps in disinfectant solution
4. Place the tray on a flat surface or a Mayo
stand.
Procedure
NOTE: Make sure the work area is clean
1. Assemble all equipment. and dry, and there is sufficient room to
work.
2. Wash hands.
390 CHAPTER 14
PROCEDURE 14:8B
5. Open the package that contains the up to create a sterile field. Holding on to
sterile towel. Be sure it is held away from the outside edges of the towel, fanfold
your body. Place the wrapper on a sur- the back of the towel so the towel can be
face away from the tray or work area. used later to cover the supplies.
Touch only the outside of the towel. Pick
CAUTION: Do not reach across the top
up the towel at its outer edge. Allow it to
of the sterile field. Reach in from either
open by releasing the fanfolds (figure
side.
14-38A). Place the towel with the outer
side (side you have touched) on the tray NOTE: If you are setting up a relatively
or Mayo stand (figure 14-38B). The large work area, one towel may not be
untouched, or sterile, side will be facing large enough when fanfolded to cover
the supplies. In such a case, you will
need a second sterile towel (later) to
cover your sterile field.
CAUTION: At all times, make sure that
you do not touch the sterile side of the
towel. Avoid letting the towel come in
contact with your uniform, other
objects, or contaminated areas.
6. Correctly unwrap the package contain-
ing the sterile basin. Place the basin on
the sterile field. Do not place it close to
the edge.
NOTE: A 2-inch border around the out-
side edges of the sterile field is consid-
FIGURE 14-38A Pick up the sterile towel at ered to be contaminated. No equipment
its outer edge and allow it to open by releasing should come in contact with this border.
the fanfolds. CAUTION: Make sure that the wrapper
does not touch the towel while placing
the basin in position.
7. Unwrap the package containing the
sterile cotton balls or gauze sponges.
Use a dropping motion to place them in
the basin. Do not touch the basin with
the wrapper.
8. Unwrap the package containing the
larger dressing. Use the sterile forceps
to remove the dressing from the pack-
age and place it on the sterile field. Make
sure the dressing is not too close to the
edge of the sterile field.
NOTE: The larger, outside dressing is
FIGURE 14-38B Place the towel on the Mayo placed on the sterile field first (before
stand without reaching across the top of the other dressings). In this way, the sup-
towel. plies will be in the order of use. For
PROCEDURE 14:8B
example, gauze dressings placed directly
on the skin will be on top of the pile, and
a thick abdominal pad used on top of
the gauze pads will be on the bottom of
the pile.
NOTE: The forceps must be lifted
straight up out of the container and
must not touch the side or rim of the
container. Keep the tips pointed down
and above the waist at all times. Shake
off excess disinfectant solution.
9. Unwrap the inner dressings correctly.
Use the sterile forceps to place them on
top of the other dressings on the sterile
field, or use a drop technique.
NOTE: Dressings are now in a pile; the FIGURE 14-39 Avoid splashing the solution
dressing that will be used first is on the onto the sterile field while pouring it into the
top of the pile. basin.
NOTE: The number and type of dress-

ings needed is determined by checking
NOTE: A second sterile towel may be
the patient being treated.
used to cover the supplies if the sterile
10. Open the bottle containing the correct field area is too large to be covered by
antiseptic solution. Place the cap on the the one fanfolded towel (figure 14-40).
table, with the inside of the cap facing CAUTION: Never reach across the top of
up. Pour a small amount of the solution the sterile tray.
into the sink to clean the lip of the bot-
tle. Then hold the bottle over the basin
and pour a sufficient amount of solu-
tion into the basin (figure 14-39).
CAUTION: Make sure that no part of the
bottle touches the basin or the sterile
field. Pour carefully to avoid splashing.
If the sterile field gets wet, the entire tray
will be contaminated, and you must
begin again.
11. Check the tray to make sure all needed
equipment is on it.
12. Pick up the fanfolded edge of the towel
by placing one hand on each side edge
of the towel on the underside, or con-
taminated side. Do not touch the sterile
side. Keep your hands and arms to the
side of the tray, and bring the towel for-
FIGURE 14-40 Use a second sterile towel to
cover the sterile towel to cover the sterile field,
ward to cover the supplies.
taking care not to reach across the field.
392 CHAPTER 14
PROCEDURE 14:8B
13. Once the sterile tray is ready, never allow
it out of your sight. Take it to the patient
area and use it immediately. If you need
more equipment, you must take the tray Practice
with you. This is the only way to be com- Go to the workbook and use the
pletely positive that the tray does not evaluation sheet for 14:8B,
become contaminated. Preparing a Sterile Dressing Tray, to
14. Replace equipment.
believe you have mastered this skill,
15. Wash hands. sign the sheet and give it to your
instructor for further action.

PROCEDURE 14:8C
CAUTION: If you touch the inside of the
Donning and package (where the gloves are), get a
Removing Sterile new package and start again.
Gloves 4. The glove for the right hand will be on
the right side and the glove for the left
Equipment and Supplies hand will be on the left side of the pack-
age. With the thumb and forefinger of
Sterile gloves the nondominant hand, pick up the top
edge of the folded-down cuff (inside of
Procedure glove) of the glove for the dominant
hand. Remove the glove carefully (figure
1. Assemble equipment and take it to the 14-41B).
area where it is to be used. Check the
package for stains, tears, moisture, or CAUTION: Do not touch the outside of
evidence of contamination. Do not use the glove. This is sterile. Only the part
the package if there is any evidence of that will be next to the skin can be
contamination. touched. Remember, unsterile touches
unsterile and sterile touches sterile.
2. Remove rings. Wash hands. Dry hands
thoroughly. 5. Hold the glove by the inside cuff and slip
the fingers and thumb of your other
3. Open the package of gloves, taking care hand into the glove. Pull it on carefully
not to touch the inside of the inner (figure 14-41C).
wrapper. The inner wrapper contains
the gloves. Reach in from the sides to NOTE: Hold the glove away from the
open the inner package and expose the body. Pull gently to avoid tearing the
sterile gloves (figure 14-41A). The folded glove.
cuffs will be nearest you.
PROCEDURE 14:8C
6. Insert your gloved hand under the cuff 8. Turn the cuffs up by manipulating only
(outside) of the other glove and lift the the sterile surface of the gloves (sterile
glove from the package (figure 14-41D). touches sterile). Go up under the folded
Do not touch any other area with your cuffs, pull out slightly, and turn cuffs
gloved hand while removing the glove over and up (figure 14-41F.) Do not
from the package. touch the inside of the gloves or the skin
with your gloved hand.
CAUTION: If contamination occurs, dis-
card the gloves and start again. 9. Interlace the fingers to position the
gloves correctly, taking care not to touch
7. Holding your gloved hand under the
the skin with the gloved hands (figure
cuff of the glove, insert your other hand
14-41G).
into the glove (figure 14-41E). Keep the
thumb of your gloved hand tucked in to CAUTION: If contamination occurs,
avoid possible contamination. start again with a new pair of gloves.
FIGURE 14-41A Reach in FIGURE 14-41B Pick up the FIGURE 14-41C Hold the
from the sides to open the inner first glove by grasping the glove glove securely by the cuff and
package and expose the sterile on the top edge of the folded- slip the opposite hand into the
gloves. down cuff. glove.
FIGURE 14-41D Slip the FIGURE 14-41E Hold the FIGURE 14-41F Insert the
gloved fingers under the cuff of gloved hand under the cuff gloved fingers under the cuff,
the second glove to lift it from while inserting the other hand pull out slightly, and turn the
the package. into the glove. cuffs over and up without
touching the inside of the
gloves or the skin.
394 CHAPTER 14
PROCEDURE 14:8C
ing performance of the procedure. Now
you must consider the outside of the
gloves contaminated, and the area
inside, next to your skin, clean.
13. Insert your bare fingers on the inside of
the second glove. Remove the glove by
pulling it down gently, taking care not to
touch the outside of the glove with your
bare fingers. It will be wrong side out
when removed.
FIGURE 14-41G Interlace the fingers to CAUTION: Avoid touching your uniform
position the gloves correctly, taking care not to or any other object with the contami-
touch the skin with the gloved hands. nated gloves.
10. Do not touch anything that is not sterile 14. Put the contaminated gloves in an infec-
once the gloves are in place. Gloves are tious waste container immediately after
applied for the purpose of performing removal.
procedures requiring sterile technique.
15. Wash your hands immediately and thor-
During the procedure, they will become
oughly after removing gloves.
contaminated with organisms related to
the patient’s condition, for example, 16. Once the gloves have been removed,
wound drainage, blood, or other body do not handle any contaminated
discharges. Even a clean, dry wound equipment or supplies such as soiled
may contaminate gloves. dressings or drainage basins. Protect
yourself.
NOTE: Gloved hands should remain in
position above the waist. Do not allow 17. Replace equipment if necessary.
them to fall below waist. 18. Wash hands thoroughly.
11. After the procedure requiring sterile
gloves is completed, dispose of all con-
taminated supplies before removing
gloves.
NOTE: This reduces the danger of
Practice
cross-infection caused by handling con-
evaluation sheet for 14:8C, Donning
taminated supplies without glove pro-
and Removing Sterile Gloves, to
tection.
12. To remove the gloves, use one gloved believe you have mastered this skill,
hand to grasp the other glove by the out- sign the sheet and give it to your
side of the cuff. Taking care not to touch instructor for further action.
the skin, remove the glove by pulling it
down over the hand. It will be wrong
side out when removed.
NOTE: This prevents contamination of listed on the evaluation sheet, your
your hands by organisms picked up dur- instructor will grade your performance.
PROCEDURE 14:8D
7. Screen the unit or draw curtains to pro-
Changing a Sterile vide privacy for the patient. If the patient
Dressing is in a bed, elevate the bed to a comfort-
able working height and lower the side-
Equipment and Supplies rail. Expose the body area needing the
dressing change. Use sheets or drapes
Sterile tray with basin, solution, gauze as necessary to prevent unnecessary
sponges and pads (or a prepared sterile dress- exposure of the patient.
ing package); sterile gloves; adhesive or non-
8. Fold down a 2- to 3-inch cuff on the top
allergic tape; disposable gloves; infectious
of the infectious waste bag. Position it in
waste bag
a convenient location. Tear off the tape
you will need later to secure the clean
Procedure dressing. Place it in an area where it will
be available for easy access.
1. Check doctor’s written orders or obtain
orders from immediate supervisor. 9. Put on disposable, nonsterile gloves.
Gently but firmly remove the tape from
NOTE: Dressings should not be changed
the soiled dressing. Discard it in the
without orders.
infectious waste bag. Hold the skin taut
NOTE: The policy of your agency will and then lift the dressing carefully, tak-
determine how you obtain orders for ing care not to pull on any surgical
procedures. drains. Note the type, color, and amount
2. Assemble equipment. Check autoclave of drainage on the dressing. Discard
indicator and date on all equipment. If dressing in the infectious waste bag.
more than 30 days have elapsed, use NOTE: Surgical drains are placed in
another package with a more recent some surgical incisions to aid in the
date. Put the unsterile package aside for removal of secretions. Care must be
resterilization. taken to avoid moving the drains when
3. Wash hands thoroughly. the dressing is removed.
4. Prepare a sterile tray as previously 10. Check the incision site. Observe the type
taught in Procedure 14:8B or obtain a and amount of remaining drainage, color
commercially prepared sterile dressing of drainage, and degree of healing.
package. CAUTION: Report any unusual obser-
NOTE: Prepared packages are used in vations immediately to your supervisor.
some agencies. Examples are bright red blood, pus,
swelling, or abnormal discharges at the
CAUTION: Never let the tray out of your wound site or patient complaints of
sight once it has been prepared. pain or dizziness.
5. Take all necessary equipment to the 11. Remove disposable gloves and place in
patient area. Place it where it will be infectious waste bag. Immediately wash
convenient for use yet free from possi- your hands.
ble contamination by other equipment.
CAUTION: Nonsterile disposable gloves
6. Introduce yourself. Identify the patient. should be worn while removing dress-
Explain the procedure. Close the door ings to avoid contamination of the
and/or windows to avoid drafts and flow hands or skin by blood or body dis-
of organisms into the room. charge.
396 CHAPTER 14
PROCEDURE 14:8D
12. Fanfold the top cover back to uncover 16. Do not cleanse directly over the wound
the sterile field. unless there is a great deal of drainage
or it is specifically ordered by the physi-
CAUTION: Handle only the contami-
cian. If this is to be done, use sterile
nated (outside) side of the towel. The
gauze and wipe with a single stroke from
side in contact with the tray’s contents
the top to the bottom. Discard the soiled
is the sterile side.
gauze. Repeat as necessary, using a new
NOTE: If a prepared package is used, sterile gauze sponge each time.
open it at this time.
17. The wound is now ready for clean dress-
13. Don sterile gloves as previously taught ings. Lift the sterile dressings from the
in Procedure 14:8C. tray and place them lightly on the
14. Using thumb and forefinger, pick up a wound. Make sure they are centered
gauze sponge from the basin. Squeeze it over the wound.
slightly to remove any excess solution. NOTE: The inner dressing is usually
Warn the patient that the solution may made up of 4-by-4-inch gauze sponges.
be cool.
18. Apply outer dressings until the wound is
15. Cleanse the wound. Use a circular sufficiently protected.
motion (figure 14-42).
NOTE: Heavier dressings such as
NOTE: Begin near the center of the abdominal pads are usually used.
wound and move outward or away from
NOTE: The number and size of dress-
the wound. Make an ever-widening cir-
ings needed to dress the wound will
cle. Discard the wet gauze sponge after
depend on the amount of drainage and
use. Never go back over the same area
the size of the wound.
with the same gauze sponge. Repeat this
procedure until the area is clean, using a 19. Remove the sterile gloves as previously
new gauze sponge each time. taught. Discard them in the infectious
waste bag. Immediately wash your
hands.
20. Place the precut tape over the dressing
at the proper angle. Check to make sure
that the dressing is secure and the ends
are closed.
NOTE: Tape should be applied so it runs
opposite from body action or move-
ment (figure 14-43). It should be the
correct width for the dressing. It should
Start in be long enough to support the dressing,
center
but it should not be too long because it
will irritate the patient’s skin.
21. Check to be sure the patient is comfort-
End able and that safety precautions have
been observed before leaving the area.
FIGURE 14-42 Use a circular motion to clean
the wound, starting at the center of the wound 22. Put on disposable, nonsterile gloves.
and moving in an outward direction. Clean and replace all equipment used.
PROCEDURE 14:8D
of drainage, and any other pertinent
information, or tell this information to
your immediate supervisor.
Example: 1/8/—, 9:00 A.M. Dressing
changed on right abdominal area. Small
amount of thick, light-yellow discharge
noted on dressings. No swelling or
inflammation apparent at incision site.
Sterile dressing applied. Your signature
and title.
NOTE: Report any unusual observations
immediately.
FIGURE 14-43 Tape should be applied
so that it runs opposite to body action or
movement.
Tie or tape the infectious waste bag
securely. Dispose of it according to
agency policy.
Practice
CAUTION: Disposable, nonsterile gloves evaluation sheet for 14:8D,
should be worn to provide a protective Changing a Sterile Dressing, to
barrier while cleaning equipment or practice this procedure. When you
supplies that may be contaminated by believe you have mastered this skill,
blood or body fluids. sign the sheet and give it to your
23. Remove disposable gloves. Wash hands instructor for further action.
thoroughly. Protect yourself from possi-
ble contamination.
24. Record the following information on the Final Checkpoint Using the criteria
patient’s chart or agency form: date, listed on the evaluation sheet, your
time, dressing change, amount and type instructor will grade your performance.
14:9 INFORMATION ple at the same time. A pandemic exists when

the outbreak of disease occurs over a wide geo-
Maintaining Transmission-Based graphic area and affects a high proportion of the
Isolation Precautions population. Because individuals can travel read-
ily throughout the world, a major concern is that
INTRODUCTION worldwide pandemics will become more and
more frequent.
In health occupations, you will deal with Transmission-based isolation precau-
many different diseases/disorders. Some tions are a method or technique of caring
diseases are communicable and require isola- for patients who have communicable diseases.
tion. A communicable disease is caused by a Examples of communicable diseases are tuber-
pathogenic organism that can be easily transmit- culosis, wound infections, and pertussis (whoop-
ted to others. An epidemic occurs when the ing cough). Standard precautions, discussed in
communicable disease spreads rapidly from per- Information section 14:4, do not eliminate the
son to person and affects a large number of peo- need for specific transmission-based isolation
398 CHAPTER 14
precautions. Standard precautions are used on Two terms are extensively used in transmis-
all patients. Transmission-based isolation tech- sion-based isolation: contaminated and clean.
niques are used to provide extra protection These words refer to the presence of organisms
against specific diseases or pathogens to prevent on objects.
their spread.
♦ Contaminated, or dirty, means that objects
Communicable diseases are spread in many
contain disease-producing organisms. These
ways. Some examples include direct contact with
objects must not be touched, unless the health
the patient; contact with dirty linen, equipment,
worker is protected by gloves, gown, and other
and/or supplies; and contact with blood, body
required items.
fluids, secretions, and excretions such as urine,
feces, droplets (from sneezing, coughing, or spit- NOTE: The outside and waist ties of the gown,
ting), and discharges from wounds. Transmission- protective gloves, and mask are considered
based isolation precautions are used to limit contaminated.
contact with pathogenic organisms. These tech- ♦ Clean means that objects or parts of objects
niques help prevent the spread of the disease to do not contain disease-producing organisms
other people and protect patients, their families, and therefore have minimal chance of spread-
and health care providers. ing the disease. Every effort must be made to
The type of transmission-based isolation prevent contamination of these objects or
used depends on the causative organism of the parts of objects.
disease, the way the organism is transmitted, and NOTE: The insides of the gloves and gown are
whether the pathogen is antibiotic resistant (not clean, as are the neckband, its ties, and the
affected by antibiotics). Personal protective mask ties.
equipment (PPE) is used to provide protection
from the pathogen. Some transmission-based The Centers for Disease Control and Preven-
isolation precautions require the use of gowns, tion (CDC) in conjunction with the National
gloves, face shields, and masks (figure 14-44), Center for Infectious Diseases (NCID) and the
while others only require the use of a mask. Hospital Infection Control Practices Advisory
Committee (HICPAC) has recommended four
main classifications of precautions that must be
followed: standard, airborne, droplet, and con-
tact. Health care facilities are provided with a list
of infections/conditions that shows the type and
duration of precautions needed for each specific
disease. In this way, facilities can follow the guide-
lines to determine the type of transmission-based
isolation that should be used along with the spe-
cific precautions that must be followed.
STANDARD
PRECAUTIONS
Standard precautions (discussed in Information
section 14:4) are used on all patients. In addition,
a patient must be placed in a private room if the
patient contaminates the environment or does
not (or cannot be expected to) assist in maintain-
ing appropriate hygiene. Every health care worker
FIGURE 14-44 Some transmission-based must be well informed about standard precau-
isolation precautions require the use of gowns, tions and follow the recommendations for the
gloves, and a mask, while others only require the use of gloves, gowns, and face masks when con-
use of a mask. ditions indicate their use.
a high-efficiency particulate air (HEPA) mask

AIRBORNE (figures 14-46A, B). These masks contain spe-
PRECAUTIONS cial filters to prevent the entrance of the small
airborne pathogens. The masks must be fit
Airborne precautions (figure 14-45) are used tested to make sure they create a tight seal
for patients known or suspected to be infected each time they are worn by a health care pro-
with pathogens transmitted by airborne droplet vider. Men with facial hair cannot wear a stan-
nuclei. These are small particles of evaporated dard filtering mask because a beard prevents
droplets that contain microorganisms and remain an airtight seal. Men with facial hair can use a
suspended in the air or on dust particles. Exam- special HEPA-filtered hood.
ples of diseases requiring these isolation precau- ♦ People susceptible to measles or chicken pox
tions are rubella (measles), varicella (chicken should not enter the room.
pox), tuberculosis, and shingles or herpes zoster
♦ If at all possible, the patient should not be
(varicella zoster). Standard precautions are used
moved from the room. If transport is essential,
at all times. In addition, the following precautions
however, the patient must wear a surgical
must be taken:
mask during transport to minimize the release
♦ The patient must be placed in a private room, of droplets into the air.
and the door should be kept closed.
♦ Air in the room must be discharged to outdoor
air or filtered before being circulated to other DROPLET PRECAUTIONS
areas. Droplet precautions (figure 14-47) must be fol-
♦ Each person who enters the room must wear lowed for a patient known or suspected to be
respiratory protection in the form of an N95, infected with pathogens transmitted by large-
P100 or more powerful filtering mask such as particle droplets expelled during coughing, sneez-
AIRBORNE PRECAUTIONS
In Addition to Standard Precautions
Visitors - Report to Nurses' Station Before Entering Room
BEFORE CARE DURING CARE AFTER CARE
1. Private room and closed 1. Limit transport of patient/resident 1. Bag linen to
door with monitored to essential purposes prevent contamination
negative air pressure, only. Patient resident of self, environment, or
frequent air exchanges, must wear mask outside of bag.
and high-efficiency filtration. appropriate for
disease.
2. Wash hands.
2. Discard infectious trash
to prevent contamination
of self, environment, or
2. Limit use of outside of bag.
noncritical care
equipment to
3. Wear respiratory protection a single
appropriate for disease. patient/resident.
3. Wash hands.
FIGURE 14-45 Airborne precautions. (Courtesy of Brevis Corporation)
400 CHAPTER 14
FIGURE 14-46A The N95 respirator mask.

(Courtesy of 3M Company, St. Paul, MN)
FIGURE 14-46B The P100 respirator mask.
(Courtesy of 3M Company, St. Paul, MN)
ing, talking, or laughing. Examples of diseases pneumonia, sinusitis, and otitis media; diphthe-
requiring these isolation precautions include ria; Mycoplasma pneumonia; pertussis; adenovi-
Haemophilus influenzae meningitis and pneu- rus; mumps; and severe viral influenza. Standard
monia; Neisseria meningitis and pneumonia; precautions are used at all times. In addition, the
multidrug-resistant Streptococcus meningitis, following precautions must be taken:
DROPLET PRECAUTIONS
1. Private room. 1. Limit transport of patient/resident 1. Bag linen to
Maintain 3 feet of to essential purposes prevent contamination
spacing between only. Patient/resident of self, environment, or
patient/resident must wear mask outside of bag.
and visitors. appropriate for
disease.

2. Mask/face shield for staff 2. Limit use of outside of bag.
and visitors within 3 feet noncritical care
of patient/resident. equipment to
a single 3. Wash hands.
patient/resident.
FIGURE 14-47 Droplet precautions. (Courtesy of Brevis Corporation)
♦ The patient should be placed in a private enterohemorrhagic E. coli, Shigella, hepatitis A,

room. If a private room is not available and or rotavirus; viral or hemorrhagic conjunctivitis
the patient cannot be placed in a room with a or fevers; and any skin infections that are highly
patient who has the same infection, a distance contagious or that may occur on dry skin, such as
of at least 3 feet should separate the infected diphtheria, herpes simplex virus, impetigo,
patient and other patients or visitors. pediculosis (head or body lice), scabies, and
staphylococcal infections. Standard precautions
♦ Masks must be worn when working within 3 are used at all times. In addition, the following
feet of the patient, and the use of masks any-
precautions must be taken:
where in the room is strongly recommended
♦ The patient should be placed in a private
♦ If transport or movement of the patient is room or, if a private room is not available, in a
essential, the patient must wear a surgical
room with a patient who has an active infec-
mask.
tion caused by the same organism.
♦ Gloves must be worn when entering the
CONTACT PRECAUTIONS room.
♦ Gloves must be changed after having contact
Contact precautions (figure 14-48) must be with any material that may contain high con-
followed for any patients known or suspected to centrations of the microorganism, such as
be infected with epidemiologically (capable of wound drainage or fecal material.
spreading rapidly from person to person, an epi-
demic) microorganisms that can be transmitted ♦ Gloves must be removed before leaving the
by either direct or indirect contact. Examples of room, and the hands must be washed with an
diseases requiring these precautions include any antimicrobial agent.
gastrointestinal, respiratory, skin, or wound ♦ A gown must be worn in the room if there is any
infections caused by multidrug-resistant organ- chance of contact with the patient, environ-
isms; diapered or incontinent patients with mental surfaces, or items in the room. The
CONTACT PRECAUTIONS
1. Private room. 1. Limit transport of patient/resident 1. Bag linen to
to essential purposes prevent contamination
only. Patient/resident of self, environment, or
must wear mask outside of bag.
appropriate for
2. Wash hands. disease.
3. Wear gown if soiling is likely. 2. Limit use of outside of bag.
noncritical care
equipment to
a single
patient/resident. 3. Wash hands.
4. Wear gloves when
entering room.
Change after contact
with infective material.
FIGURE 14-48 Contact precautions. (Courtesy of Brevis Corporation)
402 CHAPTER 14
gown must be removed before leaving the room ♦ Frequent disinfection occurs while the patient
and care must be taken to ensure that clothing occupies the room
is not contaminated after gown removal.
♦ Anyone entering the room must wear clean or
♦ Movement and transport of the patient from sterile gowns, gloves, and masks
the room should be for essential purposes
only.
♦ All equipment or supplies brought into the
room are clean, disinfected, and/or sterile
♦ The room and items in it must receive daily
cleaning and disinfection as needed.
♦ Special filters may be used to purify air that
enters the room
♦ If possible, patient-care equipment (bedside
commode, stethoscope, sphygmomanometer,
♦ Every effort is made to protect the patient
from microorganisms that cause infection or
thermometer) should be left in the room and
disease
used only for this patient. If this is not possi-
ble, all equipment must be cleaned and disin-
fected before being used on another patient.
SUMMARY
Exact procedures for maintaining transmission-
PROTECTIVE OR based isolation precautions vary from one facility
REVERSE ISOLATION to another. The procedures used depend on the
type of units provided for isolation patients, and
Protective or reverse isolation refers to meth- on the kind of supplies or special isolation equip-
ods used to protect certain patients from organ- ment available. Most facilities convert a regular
isms present in the environment. Protective patient room into an isolation room, but some
isolation is used mainly for immunocompromised facilities use special, two-room isolation units.
patients, or those whose body defenses are not Most facilities use disposable supplies such as
capable of protecting them from infections and gloves, gowns, and treatment packages. There-
disease. Examples of patients requiring this pro- fore, it is essential that you learn the isolation
tection are patients whose immune systems have procedure followed by your agency. However, the
been depressed prior to receiving transplants basic principles for maintaining transmission-
(such as bone marrow transplants), severely based isolation are the same regardless of the
burned patients, patients receiving chemother- facility. Therefore, if you know these basic prin-
apy or radiation treatments for cancer, or patients ciples, you will be able to adjust to any setting.
whose immune systems have failed. Precautions
vary depending on the patient’s condition. Stan-
dard precautions are used at all times. In addi-
tion, the following precautions may be taken:
STUDENT: Go to the workbook and complete
the assignment sheet for 14:9, Maintaining
♦ The patient is usually placed in a room that Transmission-Based Isolation Precautions. Then
has been cleaned and disinfected return and continue with the procedures.
PROCEDURE 14:9A
transmission-based isolation, follow
Donning and only the steps that apply.
Removing
Transmission-Based Equipment and Supplies
Isolation Garments Isolation gown, surgical mask, gloves, small
NOTE: The following procedure deals plastic bag, linen cart or container, infectious
with contact transmission-based isola- waste container, paper towels, sink with run-
tion precautions. For other types of ning water
PROCEDURE 14:9A
Procedure NOTE: The tie bands on the mask are
considered clean. The mask is consid-
1. Assemble equipment. ered contaminated.
NOTE: In many agencies, clean isola- NOTE: The mask is considered to be
tion garments and supplies are kept contaminated after 30 minutes in isola-
available on a cart outside the isolation tion or anytime it gets wet. If you remain
unit, or in the outer room of a two-room in isolation longer than 30 minutes, or if
unit. A waste container should be posi- the mask gets wet, you must wash your
tioned just inside the door. hands, and remove and discard the old
mask. Then wash your hands again, and
2. Wash hands. put on a clean mask.
3. Remove rings and place them in your 6. If uniform sleeves are long, roll them up
pocket or pin them to your uniform. above the elbows before putting on the
4. Remove your watch and place it in a gown.
small plastic bag or centered on a clean 7. Lift the gown by placing your hands
paper towel. If placed on a towel, handle inside the shoulders.
only the bottom part of the towel; do not
touch the top. NOTE: The inside of the gown and the
ties at the neck are considered clean.
NOTE: The watch will be taken into the
room and placed on the bedside stand NOTE: Most agencies use disposable
for taking vital signs. Because it cannot gowns that are discarded after use.
be sterilized, it must be kept clean. 8. Work your arms into the sleeves of the
NOTE: In some agencies, a plastic-cov- gown by gently twisting (figure 14-49B).
ered watch is left in the isolation room. Take care not to touch your face with
the sleeves of the gown.
5. Put on the mask. Secure it under your
chin. Make sure to cover your mouth 9. Place your hands inside the neckband,
and nose. Handle the mask as little as adjust until it is in position, and then tie
possible. Tie the mask the bands at the back of your
securely behind your head neck (figure 14-49C).
and neck. Tie the top ties
first and the bottom ties
second (figure 14-49A).
FIGURE 14-49B After tying

the mask in place, put on the
FIGURE 14-49A Put on the gown by placing your hands FIGURE 14-49C Slip your
mask, tying the top ties before inside the shoulders to ease fingers inside the neckband to
the bottom ties. your arms into the sleeves. tie the gown at the neck.
404 CHAPTER 14
PROCEDURE 14:9A
10. Reach behind and fold the edges of the NOTE: The waist ties are considered
gown over so that the uniform is com- contaminated.
pletely covered. Tie the waistbands (fig-
15. If gloves are worn, remove the first glove
ure 14-49D). Some waistbands are long
by grasping the outside of the cuff with
enough to wrap around your body
the opposite gloved hand. Pull the glove
before tying.
over the hand so that the glove is inside
11. If gloves are to be worn, put them on. out (figure 14-50B). Remove the second
Make sure that the cuff of the glove glove by placing the bare hand inside
comes over the top of the cuff of the the cuff. Pull the glove off so it is inside
gown (figure 14-49E). In this way, there out. Place the disposable gloves in the
are no open areas for entrance of organ- infectious waste container.
isms.
16. To avoid unnecessary transmission of
12. You are now ready to enter the isolation organisms, use paper towels to turn on
room. Double-check to be sure you have the water faucet. Wash and dry your
all equipment and supplies that you will hands thoroughly. When they are dry,
need for patient care before you enter use a clean, dry paper towel to turn off
the room. the faucet.
13. When patient care is complete, you will CAUTION: Organisms travel rapidly
be ready to remove isolation garments. through wet towels.
In a two-room isolation unit, go to the
17. Untie the bottom ties of the mask first
outer room. In a one-room unit, remove
followed by the top ties. Holding the
garments while you are standing close
mask by the top ties only, drop it into
to the inside of the door. Take care to
the infectious waste container (figure
avoid touching the room’s contami-
14-50C).
nated articles.
NOTE: The ties of the mask are consid-
14. Untie the waist ties (figure 14-50A).
ered clean. Do not touch any other part
Loosen the gown at the waist.
of the mask, because it is considered
contaminated.
FIGURE 14-49D Overlap the back edges of FIGURE 14-49E Put on gloves making sure
the gown so your uniform is completely covered that the cuff of the glove is over the top of the
before tying the waist ties. cuff on the gown.
PROCEDURE 14:9A
18. Untie the neck ties. Loosen the gown at 22. With your hands inside the gown at the
the shoulders, handling only the inside shoulders, bring the shoulders together
of the gown. and turn the gown so that it is inside out
(figure 14-50F). In this manner, the out-
NOTE: The neck ties are considered
side of the contaminated gown is on the
clean.
inside. Fold the gown in half and then
19. Slip the fingers of one hand inside the roll it together. Place it in the infectious
opposite cuff. Do not touch the outside. waste container.
Pull the sleeve down over the hand (fig-
NOTE: Avoid excess motion during this
ure 14-50D).
procedure because motion causes the
CAUTION: The outside of the gown is spread of organisms.
considered contaminated and should
23. Wash hands thoroughly. Use dry, clean
not be touched.
paper towels to operate the faucets.
20. Using the gown-covered hand, pull the
24. Touch only the inside of the plastic bag
sleeve down over the opposite hand
to remove your watch. Discard the bag
(figure 14-50E).
in the waste container. If the watch is on
21. Ease your arms and hands out of the a paper towel, handle only the “clean,”
gown. Keep the gown in front of your top portion (if necessary). Discard the
body and keep your hands away from towel in the infectious waste container.
the outside of the gown. Use as gentle a
25. Use a clean paper towel to open the
motion as possible.
door. Discard the towel in the waste
NOTE: Excessive flapping of the gown container before leaving the room.
will spread organisms.
CAUTION: The inside of the door is con-
sidered contaminated.
FIGURE 14-50A Untie the

waist ties of the gown before
removing the gloves.
FIGURE 14-50B To remove FIGURE 14-50C Remove the

the gloves, pull them over the mask and hold only the top ties
hand so the glove is inside out. to drop it in an infectious waste
container.
406 CHAPTER 14
PROCEDURE 14:9A
FIGURE 14-50D To remove FIGURE 14-50E Using the FIGURE 14-50F With your
the gown, slip the fingers of one gown-covered hand, grasp the hands inside the gown at the
hand under the cuff of the outside of the gown on the shoulders, bring the shoulders
opposite arm to pull the gown opposite arm and pull the gown together and turn the gown so
down over the opposite hand. down over the hand. that it is inside out, with the
contaminated side on the inside.
NOTE: The waste container should be
positioned just inside the door of the
room.
26. After leaving the isolation room, wash
Practice
hands thoroughly. This will help prevent evaluation sheet for 14:9A, Donning
spread of the disease. It also protects and Removing Transmission-Based
you from the illness. Isolation Garments, to practice this
procedure. When you believe you
Final Checkpoint Using the criteria have mastered this skill, sign the
listed on the evaluation sheet, your sheet and give it to your instructor
instructor will grade your performance. for further action.
PROCEDURE 14:9B
Working in a Hospital Procedure
Transmission-Based 1. Assemble all equipment.
Isolation Unit NOTE: Any equipment or supplies to be
used in the isolation room must be
Equipment and Supplies assembled prior to entering the room.
2. Wash hands.
Clothes hamper, two laundry bags, two trays,
dishes, cups, bowls, waste container lined 3. Put on appropriate isolation garments
with a plastic bag, infectious waste bags, bags, as previously instructed.
tape, pencil, pen, paper
PROCEDURE 14:9B
4. Tape paper to the outside of the isola-
tion door. This will be used to record
vital signs.
5. Enter the isolation room. Take all needed
equipment into the room.
6. Introduce yourself. Greet and identify
patient. Provide patient care as needed.
NOTE: All care is provided in a routine
manner. However, transmission-based
isolation garments must be worn as
ordered.
7. To record vital signs:
a. Take vital signs using the watch in the
plastic bag. (If the watch is not in a
plastic bag, hold it with the bottom
part of a paper towel.) Use other
equipment in the room as needed.
b. Open the door touching only the
FIGURE 14-51 To transfer food into an
isolation unit, a health care worker holds the
inside, or contaminated side.
tray so the worker in isolation can transfer the
c. Using a pencil, record the vital signs food onto the tray kept inside the unit.
on the paper taped to the door. Do
not touch the outside of the door at e. Glasses should be held near the top
any time. by the transfer person on the outside.
NOTE: The pencil remains in the room The transfer person on the inside
because it is contaminated. should receive the glasses by holding
them on the bottom.
8. To transfer food into the isolation unit:
9. To dispose of leftover food or waste:
a. Transfer of food requires two people;
one person must stay outside the unit a. Liquids can be poured down the sink
and one inside. or flushed down the toilet.
b. The person inside the isolation unit b. Soft foods such as mashed potatoes
picks up the empty tray in the room or cooked vegetables can be flushed
and opens door, touching only the down the toilet.
inside of the door. c. Hard particles of food, such as bone,
c. The person outside holds the tray should be placed in the plastic-lined
while the dishes are being transferred trash container.
(figure 14-51). d. Disposable utensils or dishes should
d. When transferring food, the two be placed in the plastic-lined trash
people should handle the opposite container.
sides of the dishes. In this manner, e. Metal utensils should be washed and
one person will not touch the other kept in the isolation room to be used
person. as needed for other meals. These
408 CHAPTER 14
PROCEDURE 14:9B
utensils, however, are contaminated. c. Tie a knot at the top of the bag to seal
When they are removed from the iso- it or fold the top edge twice and tape
lation room, they must be disinfected it securely.
or double bagged and labeled before
d. Place this bag inside a cuffed biohaz-
being sent for decontamination and
ardous waste bag held by a “clean”
reprocessing.
person outside the unit (figure 14-
10. To transfer soiled linen from the unit, 52).
two people are required:
e. The outside person then ties the
a. All dirty linen should be folded and outer bag securely or tapes the outer
rolled. bag shut.
b. Place linen in the linen hamper. f. The double-bagged trash should then
be burned. Double-bagged infectious
c. The person outside the unit should
waste is autoclaved prior to incinera-
cuff the top of a clean infectious
tion or disposal as infectious waste
waste laundry bag and hold it. Hands
according to legal requirements.
should be kept on the inside of the
bag’s cuff to avoid contamination. g. At all times, direct contact between
the two people transferring trash
d. The person in isolation should seal
must be avoided.
the isolation bag. The bag is then
placed inside the outer bag, which is 12. To transfer equipment from the isola-
being held by the person outside. tion unit two people are required:
e. Outer bag should be folded over at
the top and taped by the person out-
side. The bag should be labeled as
“BIOHAZARDOUS LINEN.”
f. At all times, no direct contact should
occur between the two people trans-
ferring linen.
NOTE: Many agencies use special isola-
tion linen bags. Hot water dissolves the
bags during the washing process. There-
fore, no other personnel handle the
contaminated linen after it leaves the
isolation unit.
11. To transfer trash from the isolation unit,
two people are required:
a. Any trash in the isolation room
should be in plastic bags. Any trash
or disposable items contaminated
with blood, body fluids, secretions,
or excretions should be placed in FIGURE 14-52 To transfer infectious waste
from an isolation unit, the worker in the unit
infectious waste bags.
places the sealed infectious waste bag inside a
b. When the bag is full, expel excess air second bag held by a “clean” worker outside the
by pushing gently on the bag. unit.
PROCEDURE 14:9B
a. Thoroughly clean and disinfect all transferred out of the unit using the
equipment in the unit. appropriate isolation technique.
b. After cleaning, place equipment in a 14. Before leaving an isolation room, ask
plastic bag or special isolation bag. the patient whether a urinal or bedpan
Label the bag with the contents and is needed. This will save time and energy
the word “ISOLATION.” by reducing the need to return to pro-
vide additional patient care shortly after
c. After folding the bag down twice at
leaving. Also, prior to leaving, check all
the top, tape the bag shut.
safety and comfort points to make sure
d. A second person outside the isola- patient care is complete.
tion room should hold a second,
15. Remove isolation garments as previ-
cuffed infectious waste bag.
ously instructed in Procedure 14:9A.
e. The person in isolation places the
16. Wash hands thoroughly.
sealed, contaminated bag inside the
bag being held outside the unit. The
person in isolation should have no
direct contact with the clean bag.
f. The person outside the unit turns Practice
down the top of the infectious waste Go to the workbook and use the
bag twice and securely tapes the bag. evaluation sheet for 14:9B, Working
The outside person then labels the in a Hospital Transmission-Based
bag with the contents, for example, Isolation Unit, to practice this
“ISOLATION DISHES.” procedure. When you believe you
g. The double-bagged material is then have mastered this skill, sign the
sent to Central Supply or another sheet and give it to your instructor
designated area for sterilization and/ for further action.
or decontamination.
13. The transmission-based isolation unit Final Checkpoint Using the criteria
must be kept clean and neat at all times. listed on the evaluation sheet, your
Equipment no longer needed should be instructor will grade your performance.
CHAPTER 14 SUMMARY that could be used for bioterrorism. In today’s

world, it is likely that an attack will occur. Every
health care worker must constantly be alert to
Understanding the basic principles of infection the threat of bioterrorism. Careful preparation
control is essential for any health care worker in of a comprehensive plan against bioterrorism
any health care field. Disease is caused by a wide and thorough training of all individuals can
variety of pathogens, or germs. An understand- limit the effect of the attack and save the lives of
ing of the types of pathogens, methods of trans- many people.
mission, and the chain of infection allows health Asepsis is defined as “the absence of disease-
care workers to take precautions to prevent the producing microorganisms, or pathogens.” Vari-
spread of disease. ous levels of aseptic control are possible. Anti-
Bioterrorism is the use of microorganisms as sepsis refers to methods that prevent or inhibit
weapons to infect humans, animals, or plants. the growth of pathogenic organisms. Proper
The CDC has identified and classified agents handwashing and using an ultrasonic unit to
410 CHAPTER 14
TODAY’S RESEARCH: TOMORROW’S HEALTH CARE

Super water that kills germs?
Treating chronic wounds is a multibillion-dollar market worldwide. Any health product
catalog advertises hundreds of antiseptics and disinfectants designed to kill germs. How-
ever, many of these products irritate the skin, and only a few can be used on open infected
sores.
Now scientists have created a superoxygenated water, Microcyn, that appears to kill bac-
teria, viruses, fungi, mold, and spores. Microcyn is water mixed with salt that has been charged
with an electric current to create superoxidized water. The highly oxidized water contains
hydrogen ions that have been split. The ions surround and rupture the cell wall of a single-
cell organism, such as a bacterium or virus, and cause the organism to lose its cytoplasm,
effectively killing the cell. Multicellular organisms, such as humans, are not affected by the
ions because their cells are packed closely together, forming an effective wall to prevent the
superoxygenated water from surrounding the cells. Early tests show that chronic diabetic
ulcers and burns heal quickly when this solution is used in place of other antiseptics.
In the United States, approximately 18.2 million people, or 6.3 percent of the population,
have diabetes. As the disease progresses, many of these individuals experience develop-
ment of chronic ulcers that do not heal. Statistics show that more than 60 percent of non-
traumatic lower leg amputations occur in people with diabetes. Many amputations could be
avoided if chronic ulcers could be healed. In addition, think of the many other uses for this
superwater. It could be used as an effective handwashing agent. It could be used as a spray
mist to disinfect a room. It might even prove to be an agent that can be used to stop a flu
epidemic or a biologic terrorist attack. If this superwater can destroy many of the germs that
cause disease, it will change health care.
clean instruments and supplies are examples. the recommended standard precautions while
Disinfection is a process that destroys or kills working with all patients.
pathogenic organisms, but is not always effec- Sterile techniques are used in specific pro-
tive against spores and viruses. Chemical disin- cedures, such as changing dressings. Health
fectants are used for this purpose. Sterilization care workers must learn and follow sterile tech-
is a process that destroys all microorganisms, niques when they are required to perform these
including spores and viruses. The use of an au- procedures.
toclave is an example. Instruments and equip- Transmission-based isolation precautions
ment are properly prepared, and then processed are used for patients who have communicable
in the autoclave to achieve sterilization. diseases, or diseases that are easily transmitted
Following the standard precautions estab- from one person to another. An awareness of
lished by the CDC helps prevent the spread of the major types of transmission-based isolation
pathogens by way of blood, body fluids, secre- presented in this unit will help the health care
tions, and excretions. The standard precautions worker prevent the transmission of communi-
provide guidelines for handwashing; wearing cable diseases.
gloves; using gowns, masks, and protective eye- Infection control must be followed when
wear when splashing is likely; proper handling performing any and every health care proce-
and disposal of contaminated sharp objects; dure. By learning and following the principles
proper disposal of contaminated waste; and discussed in this unit, health care workers will
proper methods to wipe up spills of blood, body protect themselves, patients, and others from
fluids, secretions, and excretions. Every health disease.
care worker must be familiar with and follow
and Prevention Act, Standard Precautions, and

INTERNET SEARCHES Transmission-Based Isolation Precautions
(airborne precautions, droplet precautions,
Use the suggested search engines in Chapter 12:4 and contact precautions)
of this textbook to search the Internet for addi-
tional information on the following topics: 8. Medical supply companies: search for names of
specific medical supply companies to research
1. Organizations regulating infection control: find products available such as autoclaves, chemi-
the organization sites for the Occupational cal disinfectants, and spill clean-up kits
Safety and Health Administration (OSHA),
Centers for Disease Control and Prevention
(CDC), National Center for Infectious Diseases REVIEW QUESTIONS
(NCID), and the Hospital Infection Control
Practices Advisory Committee (HICPAC) to
1. List the classifications of bacteria by shape and
obtain information on regulations governing
give two (2) examples of diseases caused by
infection control
each class.
2. Microbiology: search for specific information
2. Draw the chain of infection and identify three
on bacteria (can also search for specific types
(3) ways to break each section of the chain.
such as Escherichia coli), protozoa, fungi,
rickettsiae, and viruses 3. Differentiate between antisepsis, disinfection,
and sterilization.
3. Diseases: obtain information on the method of
transmission, signs and symptoms, treatment, 4. Develop a plan showing at least five (5) ways
and complications for diseases such as hepati- you can protect yourself and your family from
tis B, hepatitis C, acquired immune deficiency a bioterrorism attack.
syndrome, and specific diseases listed by the
5. List eight (8) times the hands must be washed.
discussion on microorganisms in this unit
6. Name the different types of personal protective
4. Infections: research endogenous infections,
equipment (PPE) and state when each type
exogenous infections, nosocomial infections,
must be worn to meet the requirements of
and opportunistic infections
standard precautions.
5. Bioterrorism: find information on pathogens
7. What level of infection control is achieved by
that can be used as weapons, how they are
an ultrasonic cleaner? chemicals? an auto-
spread, methods for prevention and/or treat-
clave?
ment of diseases caused by the pathogens, and
bioterrorism preparedness plans developed as 8. Name three (3) methods that can be used to
a result of the Bioterrorism Act of 2002 place sterile items on a sterile field. Identify the
types of items that can be transferred by each
6. Foreign trip: plan a trip to an exotic foreign
method.
country; research the Internet to determine
specific health precautions that must be taken 9. List the three (3) types of transmission-based
during your stay, and determine which immu- isolation precautions and the basic principles
nizations you will need before the trip that must be followed for each type.
7. Infection control: locate and read the Blood-
borne Pathogen Standards, Needlestick Safety

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DIVERSIFIED

Louise Simmers, MEd, RN

Vice President, Marketing, Career and

Delmar Cengage Learning

Cengage Learning products are represented in Canada by Nelson Education, Ltd.

For your lifelong learning solutions, visit delmar.cengage.com

Visit our corporate website at www.cengage.com

Notice to the Reader

14:1 INFORMATION For example, a bacterium called Escherichia coli

♦ Bacteria: These are simple, one-celled organ- Flagellated

resistant, which means that the antibiotic is

FIGURE 14-4 An intestinal protozoan, FIGURE 14-6A Electron micrographs of the

products; enterobiasis, which is commonly

Early recognition of signs of infection

Wound care Portal Portal Medical asepsis

Sterilization Food handling

pathogenic organism could be used in a bioter- ♦ Improving communications so information

Procedure 6. Put the palm of one hand on the back of

face that comes in contact with blood or infec-

♦ Mucous membranes Care must be taken while removing gloves to

FIGURE 14-15 Gloves, a gown, a mask, and

STUDENT: Go to the workbook and complete

Final Checkpoint Using the criteria

and it will destroy all microorganisms, both

the top of the chamber and moves downward. As

FIGURE 14-23 Special plastic or paper autoclave Articles Time at

Glassware: empty, inverted 15 minutes

also specify the recommended time for the most

cles. If sterilization is desired, other methods

Procedure NOTE: Use the cleaning chart to deter-

Organisms and pathogens travel quickly

FIGURE 14-34B By using the wrap as a mitten,

Final Checkpoint Using the criteria

FIGURE 14-37 Remove the transfer or pick-

NOTE: The number and type of dress-

Final Checkpoint Using the criteria

14:9 INFORMATION ple at the same time. A pandemic exists when

a high-efficiency particulate air (HEPA) mask

FIGURE 14-45 Airborne precautions. (Courtesy of Brevis Corporation)

FIGURE 14-46A The N95 respirator mask.

2. Discard infectious trash

FIGURE 14-47 Droplet precautions. (Courtesy of Brevis Corporation)

♦ The patient should be placed in a private enterohemorrhagic E. coli, Shigella, hepatitis A,

FIGURE 14-48 Contact precautions. (Courtesy of Brevis Corporation)

FIGURE 14-49B After tying

FIGURE 14-50A Untie the

FIGURE 14-50B To remove FIGURE 14-50C Remove the

CHAPTER 14 SUMMARY that could be used for bioterrorism. In today’s

TODAY’S RESEARCH: TOMORROW’S HEALTH CARE

and Prevention Act, Standard Precautions, and

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