The following points highlight the top five applications of sterilisation and disinfection in the practice of nursing. The applications are: 1. In Medical and Surgical Wards of a General Hospital 2. Terminal Disinfection 3. In the Operation Room or Delivery Room 4. In the Infectious Disease Hospital and 5. Disinfection in Public Health Nursing.
1. In medical and surgical wards of a general hospital:
a. Hand washing
b. Thermometer technique
c. Syringe and needles
d. Surgical dressings
e. Transfer forceps
f. Catheterisation
g. Reverse precaution
2. Terminal disinfection:
a. Dishes
b. Secretions and Excretion
3. In the operation room or delivery room
4. In the infectious disease hospital
a. Bedside equipment
5. Disinfection in public health nursing
Contents
Application # 1. In Medical and Surgical Wards of a General Hospital:
a. Hand Washing:
Careful hand washing is always very essential in the following circumstances:
(i) After taking care of each patient;
(ii) Before compounding the medicines;
(iii) After dressing an infected wound;
(iv) Before each surgical dressing;
(v) After handling bedpans and urinals;
(vi) Before the patient is served with food;
(vii) Before taking her own food.
The following procedures should be adapted in good hand washing to prevent the transfer of the microorganisms by means of hands; all areas of the hands should be adequately soaped with soap suds by mechanical frictions, should be frequently, re-soaped and completely cleaned. Before assisting a surgical operation, the nurse should scrub thoroughly her hands without fail.
b. Disinfection of Oral Thermometer:
The recommended procedure:
(a) The thermometer should be wiped clean with gauze or cotton moistened in a mixture of equal parts of tincture of green soap and 70 per cent ethyl alcohol;
(b) Rinsed completely with clean water; and
(c) Submerged deeply in a solution of 1 per cent iodine and 70 per cent ethyl alcohol for 10 minutes or only in 70 per cent ethyl alcohol which is less effective without iodine. Formaldehyde and phenolic disinfectants are not fully effective against tubercle bacilli so they cannot be used. After disinfection, the thermometer should be rinsed several times in the water, kept in a clean, dry container until further use.
Rectal Thermometer:
Before use, the rectal thermometer should be lubricated in water-soluble lubricant. Petrolatum or other oily lubricants cannot be used as they prevent thorough cleaning and disinfection. Well wiped thermometer can also be sterilised with germicidal vapours, if available.
c. Syringes and Needles:
Syringes and Needles should be sterilised in the hot air oven or autoclaved since they are used mainly for hypodermic or intramuscular or intravenous injections or for withdrawal of venous blood. Boiling should not be advocated for this purpose as the spores and some viruses (Serum and infectious hepatitis virus) may resist the boiling for a longer duration.
While handling the syringes, care should be taken so that the plunger and the inside of the barrel are always sterile. With the help of sterile forceps, the shank of the needle should be carefully held and mounted on the nozzle of the syringe. The beveled edge (point) and the shaft of the needle should be protected by dry, sterile cotton or gauze.
A needle should be sterile or a test tube with needles in it should be sterilised and then the needle should be used. It is not advisable to handle with fingers the sterile gauze or cotton soaked in disinfectant which is to be placed over the sterile needle, because the skin microorganisms may trickle down from the contaminated fingers and contaminate the sterile needle.
The loaded syringe which is properly mounted with protected needle should be carried to the patient with a bottle containing skin disinfectant (1 per cent iodine in 70 per cent alcohol). Sterile disposable, plastic syringe with needle attached is available for ready use, which can save time and avoid the contamination and infection.
Sharp instruments, which cannot withstand the sterilising heat, can be mounted on racks in jars containing disinfecting solution (isopropyl alcohol, 65.26 per cent; methyl alcohol, 2.75 per cent; formaldehyde, 8 per cent; hexachlorophene, 0.5 per cent, water 23.49 per cent) which can destroy spores within 3-5 hours.
d. Surgical Dressings:
Nurse should remove the surgical dressings with a sterile forceps, but never by her fingers and these dressings should be transferred onto a newspaper, properly wrapped and put in a covered trash can for subsequent incineration. The contaminated forceps should be discarded in a covered container and boiled, cleaned and sterilised in hot air oven or autoclave.
An infected wound can be carefully covered with a new sterile dressing by touching only the outer layer of the dressing with finger or with sterile forceps. The nurse should never touch any incision or cut wound as there is possibility of transferring pathogenic microorganisms to the wound from her fingers.
e. Transfer Forceps:
It is a sterile instrument which is always found on a surgical tray. lf this transfer forceps is used properly, there is less chance of contamination. This instrument should always be sterilised in hot air oven or autoclave daily. The transfer forceps is used only to transfer sterile instruments or dressings from one sterile place to another sterile place.
If this transfer forceps touches accidently any unsterile objects, it should be discarded and re-sterilised. This instrument should be kept always submerged deep in a chemical disinfectant solution contained in a jar, it should be removed or returned to the jar in such a way that it will not touch its rim or cover. In this case, the chemical disinfection is done only to keep the instrument sterile, but not to sterilize the transfer forceps.
f. Catheterisation:
Catheterisation (removal of urine from the urinary bladder). Before following this procedure, the nurse should wash thoroughly her hands and wear immediately the sterile gloves. The external meatus of the urethra should be thoroughly washed with sterile normal saline or mild antiseptic solution to remove simply the burden of the microorganisms present in the meatus which may be introduced into the urethra or urinary bladder during the process of catheterisation. The catheter already sterilised in the autoclave should be sufficiently lubricated with sterile water soluble lubricant and it should be inserted gently without trauma to the delicate tissues, since the damaged tissues are vulnerable to the infection.
g. Reverse Precautions:
Reverse precautions are the special precautions ordered by the doctor for the patient (premature baby, patient with recent cardiac surgery, patient with artificial kidney, severe and extensive burn patient, debilitated patient), when the body resistance is lowered and is very susceptible to any infection.
For reverse precautions, the nurse should know that any one coming in contact with the patient should wash thoroughly the hands, wear gowns, masks and caps before entering the rooms. The visitor with slightest infection should not be allowed to come in contact with the patient; hence, there should be a restriction for the visitors to enter the room.
In short, everything entering the room should be cleaned or sterilized. So, vacuum cleaner or mops or cloth soaked in moist disinfectant can be used to clean and to dust. Wet mops (clothes) will not allow the dissemination of the dust in the room.
Application # 2. Terminal Disinfection:
After discharge of a patient, particularly of communicable disease, the ward, unit or room occupied by the patient should be cleaned thoroughly; the linens or covers should be washed with soap and water, dried and ironed, the equipment should be boiled and cleaned; the mattress and pillows are autoclaved, the blankets are washed; careless terminal disinfection may lead to the transfer of antibiotic resistant Staphylococcus aureus in the hospital.
a. Dishes:
The silverware plates used for eating food by the patients of communicable diseases should be boiled for 5-10 minutes, so to kill all pathogenic organisms and then washed with clean water. The waste food from the infectious disease hospitals should be disposed off after burning or disinfecting. In communicable disease hospitals, used paper plates, paper cupsetcare burned completely.
b. Secretions and Excretions:
Tissue papers used by the patient to receive the respiratory secretions and as well as the wipes should be completely burned. Copious respiratory secretions from tuberculosis patient should be collected in a waterproof container which should be packed later with sawdust or fine newspaper strips to absorb moisture from the secretions.
The container should be wrapped very carefully with newspaper and burned in the incinerator. If glass or metal container is used, it should be immersed in saponated 5 per cent solution of cresol or strong chlorine bleaching solution for one hour. The container is then washed and used again.
Urinary and intestinal excretions collected in urinal or bed pan from a communicable disease patient should be disinfected by 5 per cent chlorinated lime. Bed and body linens used for the patients in an infectious disease hospital should be soaked in saponated cresol (2 percent) or in laundry bleaching solution overnight or autoclaved or boiled. Dressing from infected skin lesions should be burned completely.
Application # 3. In the Operation Room or Delivery Room:
All articles (instruments, linens used for drapes, gowns and gloves) should be autoclaved. Some delicate eye surgery instruments, which are liable to be damaged by heat sterilisation, are sterilised by chemical agents (ethylene oxide or beta propiolactone). The tube containing sytures can be broken in a sterile towel and the sutures are transferred to the sterile place with sterile forceps.
The nurse must clean and open all instruments so that all surfaces of the instruments are exposed to the (autoclave or hot air oven) sterilisation and she should keep ready all sterilised instruments before the surgical operation or delivery. At the same time she should also keep ready sterile drapes and dressing. In operation room, she should cover her hair with a cap so that the hair or dandruff will not fall off and will not contaminate the operation theatre. To prevent the spread of the infection to the patient, she should wear the gauze mask over the nose and mouth.
Preparation of the Patient:
The skin of the operative area should be thoroughly washed:
1. The skin of the operative area should be thoroughly washed;
2. This area should be shaved to remove all hair;
3. Fatty skin secretions can be removed by the application of ether or acetone or skin disinfectant (1.5 to 3 per cent alcoholic iodine solution).
4. The cleaning of an operative area of the skin removes the microorganisms and also superficial organic material. The removal of organic material may facilitate the penetration of the disinfectant. Before assisting the surgeon for the surgical operation, the nurse should scrub her hands and forearms at least three times with water and soap containing hexachlorophene,3 per cent. This soap is commonly used in all hospitals. After soap and water scrub, all soap should be completely rinsed with clear running water.
Then the hands should be immersed in mild disinfectant solution (70 per cent ethyl alcohol). The nurse should wear a sterile gown and rubber gloves, assist the surgeons during the operation, should be responsible for the sterility during operation, if any breach in the sterility technique, she should bring it immediately to the notice of the surgeon.
Sterilisation by boiling in the hospital ward. Boiling (at 100°C) for 10 minutes kills vegetative pathogenic bacteria, rickettsiae, all viruses (except serum and infectious hepatitis virus).This method is used to disinfect instruments or syringes under circumstances where killing of vegetative forms of bacteria are required for ordinary purposes.
Application # 4. In the Infectious Disease Hospital:
In the infectious disease hospital, pathogenic organisms can be transferred from patient to patient- patient to nurse; patient to visitor and, hence, outside of the hospital.
a. Bedside Equipment:
During the entire infectious phase of the disease, the same bedpan and thermometer should be used. The bedpan and urinal should be boiled for 5-15 minutes after each use to kill all pathogenic microorganisms. The equipment’s used occasionally between patients should be disinfected or sterilised.
Otoscopes, stethoscopes and other instruments used for examination of the patients should be sufficiently immersed in the disinfectant, which is more effective than wiping with ethyl alcohol. These instruments may also be thoroughly wiped with saponated cresol solution (1 percent) followed by cleaning with clean water and drying. It is a useful method.
Application # 5. Disinfection in Public Health Nursing:
The intelligent professional nurse should be able to adapt the principles of disinfection, destruction and removal of microorganisms according to the various circumstances prevailing in public health. The public health nurse should always pay much attention to hand washing after visiting each patient, as she is going from house to house and patient to patient. She must wash her hands thoroughly so that she does not carry the infection from patient to patient.
Before leaving the headquarter, the nurse should keep ready all syringes and needles sterilised in the autoclave or hot air oven and carry with her all these sterile items or she can also carry sterile disposable plastic syringe. In an emergency, where facilities are not available, she can disinfect needles and syringes by boiling in a covered saucepan for 30 minutes for ordinary purposes.
A home oven can be used as hot air oven. Similarly, a pressure cooker can be substituted for the autoclave; the rinsing of the syringes and needles with a disinfectant solution before each injection is not advisable. Thoroughly washed and wiped thermometer may be placed in a screw cap plastic tube cushioned with the cotton at the bottom and around the wall of the tube and filled with 70 per cent alcohol.
In case of communicable disease, the public health nurse can set up an isolation room for the patient at home by keeping bedside equipment exclusively for his use. Dishes and linens used by him should be disinfected by boiling for 30 minutes. She should also educate in explicit language the members of the family about the isolation technique so that they may continue this technique later in the absence of the public health nurse.