NAVIA - NCMB 312 RLE: SURGICAL SCRUBBING (RETURN DEMONSTRATION)

SURGICAL SCRUBBING 2) Gowns of the surgical team are considered sterile in front from the chest to the level
of the sterile field. The sleeves are also considered sterile from 2 inches above the
The surgical environment is known for its stark appearance and cool temperature. The
elbow to the stockinette cuff.
surgical suite is behind double doors, and access is limited to authorized personnel. External
3) Sterile drapes are used to create a sterile field. Only the top surface of a draped
precautions include adhering to principles of surgical asepsis; strict control of the operating
table is considered sterile. During draping of a table or patient, the sterile drape is
room (OR) environment is required, including traffic pattern restrictions.
held well above the surface to be covered and is positioned from front to back.
Policies governing this environment address such issues as the health of the staff; the 4) Items should be dispensed to a sterile field by methods that preserve the sterility of
cleanliness of the rooms; the sterility of equipment and surfaces; processes for scrubbing, the items and the integrity of the sterile field. After a sterile package is opened, the
gowning, and gloving; and OR attire. To provide the best possible conditions for surgery, the edges are considered unsterile. Sterile supplies, including solutions, are delivered to
OR is situated in a location that is central to all supporting services (eg, pathology, radiology, a sterile field or handed to a scrubbed person in such a way that the sterility of the
laboratory). The OR has special air filtration devices to screen out contaminating particles, object or fluid remains intact.
dust, and pollutants. The temperature, humidity, and airflow patterns are controlled 5) The movements of the surgical team are from sterile-to-sterile areas and from
(Meeker et al., 1999). unsterile-to-unsterile areas. Scrubbed persons and sterile items contact only sterile
areas; circulating nurses and unsterile items contact only unsterile areas.
To help decrease microbes, the surgical area is divided into three (3) zones: the unrestricted 6) Movement around a sterile field must not cause contamination of the field. Sterile
zone, where street clothes are allowed; the semi restricted zone, where attire consists of areas must be kept in view during movement around the area. At least a 1-foot
scrub clothes and caps; and the restricted zone, where scrub clothes, shoe covers, caps, and distance from the sterile field must be maintained to prevent inadvertent
masks are worn. The surgeons and other surgical team members wear additional sterile contamination.
clothing and protective devices during the operation. 7) Whenever a sterile barrier is breached, the area must be considered contaminated.
A tear or puncture of the drape permitting access to an unsterile surface underneath
renders the area unsterile. Such a drape must be replaced.
Basic Guidelines for Maintaining Surgical Asepsis 8) Every sterile field should be constantly monitored and maintained. Items of doubtful
All practitioners involved in the intraoperative phase have a responsibility to provide and sterility are considered unsterile. Sterile fields should be prepared as close as
maintain a safe environment. Adherence to aseptic practice is part of this responsibility. The possible to the time of use.
eight (8) basic principles of aseptic technique follow: Surgical Hand Hygiene (also called the Surgical Scrub)
1) All materials in contact with the surgical wound and used within the sterile field  It is process of removing as many microorganisms as possible from the skin of the
must be sterile. Sterile surfaces or articles may touch other sterile surfaces or hands and arms (3 inches above the elbow) by mechanical (friction) washing with
articles and remain sterile; contact with unsterile objects at any point renders a the use of chemical disinfectant (antiseptic or antimicrobial agent) before donning
sterile area contaminated. sterile surgical attire.

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NAVIA - NCMB 312 RLE: SURGICAL SCRUBBING (RETURN DEMONSTRATION)

 Despite the antimicrobial component of the hand- and arm cleansing process, skin is The skin is inhabited by the following list of organisms:
never rendered sterile. Consider that the tap water used in the rinse is from the
 Transient organisms acquired by direct contact. Usually loosely attached to the skin
public water system. This water is not sterile and can in itself grow microbial
surface, they are almost completely mechanically removed by thorough washing
cultures. The process of surgical scrubbing is not a sterile procedure.
with soap and water.
 Resident organisms below the skin surface in hair follicles and sebaceous and sweat
Aseptic technique is intended to minimize contamination from pathogens.
glands. They are more adherent and therefore more resistant to removal. Their
Sterile technique, on the other hand, is used to create an area free from any
growth is inhibited by the chemical phase of the surgical hand-cleansing process.
microorganisms, pathogenic or otherwise.

Resident skin flora represents the microorganisms present in the hospital

 The scrub room is adjacent to the OR for safety and convenience.
environment. Prolonged exposure of skin to contaminants yields a more pathogenic
Scrub sinks with automatic sensor controls or foot- or knee-operated faucets are preferred resident population (i.e., capable of causing infection).
to eliminate the hazard of contaminating the hands after hand and arm washing.

Note: Protective eyewear should be worn when performing a surgical scrub.

Antimicrobial Skin-Cleansing Agents
(Aerosolization from the scrub brush can cause chemicals to be dispersed into the
user’s eyes.) Various antimicrobial soaps are used for surgical hand cleansing. The same antiseptic agents
are used for the patient’s skin prep. The desirable characteristics of antimicrobial agents are
Aerosolization is the dispersal of a substance (such as medicine or viral particles) as follows:
into the form of particles small and light enough to be carried on the air i.e., into an
aerosol.  Broad spectrum (something that is effective in a wide variety of ways)
 Fast acting and effective
The sink should be deep, wide, and low enough to prevent splashes. Aerated faucets  Nonirritating and non-sensitizing
prevent splatter. (Aerate supply or introducing air) A sterile gown cannot be donned over  Prolonged action (i.e., leaves an antimicrobial residue on the skin to temporarily
damp scrub attire without resultant contamination. prevent growth of microorganisms)
Scrub sinks should be used only for scrubbing or handwashing. They should not be used to  Independent of cumulative action (cumulative action state at which repeated
clean or rinse contaminated instruments or equipment. Bioburden could inadvertently be administration may produce effects that are more pronounced than those produced
transferred to personnel who scrub in the vicinity. (Bioburden is the presence of by the first amount)
microorganisms on a surface (or complete item), inside a device, or from a portion of liquid,
prior to sterilization.)

Microbiology of the Skin

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Variables in effectiveness of the antimicrobial cleansing process are bioburden, mechanical Alcohol preparations, usually in foam, contain emollients to minimize drying. If other agents
factors, chemical factors, and individual differences in skin flora. Antiseptics alter the cannot be used because of skin sensitivity, mechanical cleansing with soap to remove
physical or chemical properties of the cell membrane of microorganisms, thus destroying or transient organisms may be followed by cleansing with an alcohol-based skin cleanser.
inhibiting cellular function. More than one FDA approved antimicrobial agent is available in
Biocidal action of various concentrations of ethanol in aqueous solution against
the scrub room for personnel who are allergic or sensitive to a particular agent.
streptococcus pyrogenes
Chlorhexidine Gluconate TIME (SEC)
CONCENTRATION 10 20 30 40 50
A 4% aqueous concentration of chlorhexidine gluconate (CHG) in a soap base or 0.5% in 100 - - - - -
alcohol exerts an antimicrobial effect against gram-positive and gram-negative, fungal, and 95 + + + + +
viral microorganisms. It reacts poorly against TB microorganisms. Antimicrobial residues 90 + + + + +
bind with the stratum corneum with repeated use and produce a prolonged effect. This 80 + + + + +
agent produces effective, intermediate action and cumulative reductions of resident and 70 + + + + +
transient flora for more than 6 hours. 60 + + + + +
50 - - + + +
CHG is rarely irritating to the skin, but it is highly ototoxic and will irritate if splashed in the
40 - - - - -
eye. It can cause permanent corneal damage. Caution should be used when scrubbing with
NOTE: A minus sign (-) indicates NO biocidal action (bacterial growth); a plus sign (+)
this agent. It is an ingredient in several of the antiseptic hand gels. The alcohol-based indicates biocidal action (no bacterial growth). The Lighter area represents bacteria
chlorhexidine preparation is effective if the hands are coated in the solution for 20 to 30 killed by biocidal action
seconds after mechanical cleansing. The alcohol evaporates rapidly and has minimal odor. Water is a must in denaturing bacteria since it is a solvent that activates alcohol. Hence, 60-
Personnel with reactive airway conditions should be aware of minor volatile qualities when 95% are the most effective alcohol concentration. e.g., alcohol 60% = 40% water
using this product. Allow the product to dry thoroughly before donning gowns and gloves.
note: alcohol percentage must higher than water thus 40-50% are less effective (the higher
Iodophors concentration of alcohol than water, the higher the effectivity)
A povidone-iodine complex in detergent fulfills the criteria for an effective surgical scrub. It
is available in concentrations of 10%, 7.5%, 2%, and 0.5%. Iodophors are intermediate-acting
antimicrobial agents against gram-positive and -negative, TB, fungal, and viral Procedure for Surgical Hand Hygiene
microorganisms. Iodophors have minimal residual effect. Iodophors can be irritating to the Opening the Gown and Gloves
skin.
The scrub person wears all the appropriate attire for the restricted area before entering the
Alcohol OR (i.e., scrub suit, head cover, eye protection, and mask). The gown and gloves must be
Ethyl or isopropyl alcohol (60%-90%) is rapidly antimicrobial against all microorganisms. It is “opened” before performing surgical hand hygiene.
volatile and does not have residual activity. It is nontoxic but has a drying effect on skin.

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The double-wrapped gown package contains one sterile folded gown and towel. The outer 6. NO jewelries. All jewelry is removed from the fingers, wrists, and neck. Jewelry
wrap is a peel pouch and the inner wrap is envelope style. The gown is folded inside out to harbors microorganisms.
facilitate donning. The folded gown resembles a thick book with the main fold as its binding. 7. DON cap. All hair should be covered by headwear. Pierced-ear studs should be
A folded woven fabric or disposable paper towel for drying the hands is packed on top of the contained by the head cover because they are a potential foreign body in the
gown. The towel is folded into a square or rectangle with one corner turned down for ease surgical site. A quick look in the mirror by the scrub sink to be sure all hair is secured
of grasping without disturbing the entire gown-towel assembly. helps prevent infection.
8. DON mask. Adjust the disposable mask snugly and comfortably over the nose and
 The gown package is opened before the glove package on a separate surface from
mouth.
the main sterile field. The gown inner wrapper is removed from the peel pouch and
9. Specs. Clean your spectacles if they are to be worn. Adjust and secure protective
is used to create a temporary sterile field of its own. It is inappropriate for the scrub
eyewear or the face shield comfortably in relation to the mask and spectacles.
person establishing the sterile field to gown and glove off the main sterile field.
10. Water. Adjust water to a comfortable temperature. Cooler water helps to minimize
dry skin. Hot water can increase chafing by degreasing the skin.
 The gloves are double-wrapped in a peel pouch and folded paper. The peel pouch is
opened and the paper-wrapped gloves can be dispensed to the side of the gown on Surgical Hand and Arm Scrub with a Brush
the inner aspect of the sterile gown wrapper. Do not dispense on top of the towel.
When arriving in the surgical department for the day the first-hand cleansing should be a
The glove wrapper can be contaminated when reaching for the towel with wet
brush scrub, either timed or a counted brushstroke method. When an individual scrubs with
hands. Ideally, if another surface is available, the glove wrapper can be opened in its
a brush and antimicrobial agent the soap decreases the surface tension of the skin, thus
entirety to fashion a temporary sterile area for the purpose of donning the gloves.
permitting the shed cells to be rinsed away with the tap water. Care is taken to avoid
scrubbing longer than 3 to 5 minutes, because skin can become abraded and release
Preparations Immediately Before Surgical Hand Hygiene microorganisms from hair follicles.

1. Skin and Nails. The skin and nails should be kept clean and in good condition, and In surgical scrubbing with a brush, antiseptic soap, and water the skin is cleansed of
the cuticles should be uncut. If hand lotion is used to protect the skin, a non–oil- microorganisms using the following two properties:
based product is recommended. Oil can weaken the integrity of gloves.
1. Mechanical. The mechanical properties remove soil and transient organisms with
2. Fingernails. Fingernails should not reach beyond the fingertips to avoid glove
friction. Nails are cleaned under running water with a nail pick.
puncture.
2. Chemical. The chemical properties reduce resident flora and inactivate
3. NO fingernail polishes. Fingernail polish should not be chipped or cracked. Freshly
microorganisms with an antimicrobial or antiseptic agent.
applied polish may be worn if permitted by facility policy.
4. NO artificial nails. Artificial nails harbor microorganisms such as bacteria and fungi Debris should be removed from the subungual (under nails) area of each finger. Single-use
and are inappropriate for scrub personnel. disposable products are a brush-sponge combination with an enclosed nail cleaning pick.
5. NO skin abrasion. (Probably the pain during scrubbing and asepsis) Some brushes are individually packaged and impregnated with antiseptic-detergent agents.
Additional antiseptic solution is dispensed onto the brush or sponge by a foot pedal from a

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container adjacent to the sink. Six drops (approximately 2-3 mL) of solution are sufficient to from the cleanest area—the hands—to the marginal area of the upper arms. Take care not
generate a lather for the scrub procedure. Waste of antiseptic solution should be avoided. to slip in water that may have dripped to the floor during the process. A waterproof mat is
suggested in front of the sink.
A timed or counted brushstroke method can be used to scrub the hands and arms. A
vigorous 2- to 5-minute scrub with a reliable agent is effective. A counted brushstroke Surgical Hand Hygiene with Antiseptic Gel
method is equally effective in decreasing the microbial count on the skin. Prolonged
In an antiseptic hand gel method, the antimicrobial chemical properties of the gel kill
scrubbing raises resident microbes from deep dermal layers and is therefore
microorganisms. Antiseptic hand gels do not use mechanical action or friction. There is no
counterproductive. Care should be taken not to abrade the skin during the scrub process.
water rinse to physically remove microorganisms; the main action is chemical. The antiseptic
Denuded areas allow the entry of microorganisms. Too short a scrub may be equally
does not remove debris from under the nails and hands. That is why a simple handwashing
ineffectual.
and drying is recommended by AORN (Association of periOperative Registered Nurses) to
Every member of the surgical team should scrub according to a standardized written remove gross soil before using a surgical hand cleansing gel.
procedure. The time required may be based on the manufacturer’s recommendations for
Many gel-type surgical skin cleansers have a lasting antimicrobial effect for several hours
the agent used and documentation of the product’s efficacy in the scientific literature. A
after application. The coating of the antiseptic gel on the skin should be rubbed in evenly
copy of the procedure should be posted in every scrub room. Subsequent scrubs should
without clumps in the crook of the elbows or between the fingers. The gel is alcohol based
follow the same procedure as the initial scrub of the day.
and should be completely dry before donning the sterile gown and gloves. The material
When gloves are removed at the end of the surgical procedure, the hands are considered should not be wiped off the skin, and the hands and arms should not be waved through the
contaminated and should be immediately washed with soap and water. Resident air in a drying motion. Air currents cause particulates in the environment to disperse
microorganisms multiply rapidly in the warm, moist environment under the gloves. throughout the restricted area.
Personnel who scrub should think of their fingers, hands, and arms as having four sides or
Most brushless cleansing agents have an alcohol base with an antimicrobial ingredient such
surfaces. Both methods (timed and counted brushstroke) follow an anatomic pattern of
as CHG or triclosan. Care is taken to allow the agent to completely dry before donning the
scrubbing:
sterile gown and gloves. All products of this nature should be used as directed by the
1. the four surfaces of each finger, beginning with the thumb and moving from one manufacturer. Each product has a specific application process and drying protocol.
finger to the next, down the outer edge of the fifth finger, over the dorsal (back)
TWO (2) TYPES OF SURGICAL SCRUB
surface of the hand,
2. then the palmar (palm) surface of the hand, or vice versa, from the small finger to A. TIME METHOD: Using a clock or some other timing device to measure brushing time,
the thumb, over the wrists and up the arm, in thirds, ending 2 inches (5 cm) above the length of the scrub varies from one institution to another. This method has been
the elbow. most frequently used in the past.
Because the hands are in most direct contact with the sterile field, all steps of the scrub
 COMPLETE SCRUB - 5-7 minutes
procedure begin with cleaning the fingernails and hands and end above the elbows. During
 SHORT SCRUB - 3minutes
and after scrubbing, keep the hands higher than the elbows to allow water and suds to flow

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the sterile gown without touching them. This will ensure your gloves and
B. BRUSH STROKE METHOD A prescribed number of brush-strokes, applied lengthwise gown are untouched, and therefore sterile)
of the brush or sponge, is used for each surface of the fingers, hands, and arms.

INDICATIONS of short Scrub: after a clean case if the hands and arms have not been
contaminated in any other way.

PROCEDURE
SCRUBBING and HAND DRYING
PREPARATION (1-10 above)
(1) Regulate the flow and temperature of
1. Gather the materials to be used
the water.
 scrub suit
 cap (2) Pre-tear package containing brush (see
 mask (4-string) Figure 1-4); lay the brush on the back of the
 sterile gown scrub sink.
 sterile gloves
 brush and soap
2. Check length of fingernails, presence of artificial and nail polish to remove, remove
jewelries, and inspect for skin integrity
3. Wear appropriate attire (complete OR attire)
Figure 1-4
 Scrub suit
(3) Wet hands and arms (see Figure 1-5) for
 Cap
an initial pre-scrub wash. Use several drops
 Mask of surgical detergent, work up a heavy
 Eye wear lather, then wash the hands and arms to a
4. Opening the materials to use after scrubbing: point about two inches above the elbow.
 sterile package containing the gown and create a sterile field (Open the
gown. Carefully use the edges of the paper to open the packet and expose
the surgical gown)
 sterile gloves and drop the inner package of the gloves on the sterile field
(Peel the plastic glove packet open over the gown and drop the gloves onto
Figure 1-5

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(4) Rinse hands and arms thoroughly, (7) Lather digits (see Figure 1-9); scrub 20
allowing the water to run from the hands circular strokes on all four sides of each
to the elbows (see Figure 1-6). Do not finger.
retrace or shake the hands and arms; let
the water drip from them.

Figure 1-6 Figure 1-9

(5) Remove the sterile brush and file, You may begin with the thumb or little
moisten brush and work up a lather. Soap finger (see Figure 1-10) or the right or left
fingertips and clean the spaces under the hand. Scrub one hand and arm completely
fingernails of both hands under running before moving on to the other hand and
water (see Figure 1-7); discard file. arm.

(8) Lather palm, back of hand, heel of hand,

and space between thumb and index
finger. Choosing either of the surfaces,
scrub 20 circular strokes on each surface.
Figure 1-7
(6) Lather fingertips with sponge-side of (9) You are now ready to scrub the Figure 1-10
brush; then, using bristle side of brush, forearm. Divide your arm in three (3) inch
scrub the spaces under the fingernails of increments. The brush should be
the right or left hand 30 circular approximately three inches lengthwise. Use
strokes (see Figure 1-8). When scrubbing, the sponge-side of the brush lengthwise to
slightly bend forward, hold hands and arms apply soap around wrist. Scrub 20 circular
above the elbow, and keep arms away from strokes on all four sides; move up the
the body. forearm--lather, then scrub, ending two
inches above the elbow.

(10) Soap and/or water may be added to

Figure 1-8
the brush at any time

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through surgical cloth gowns, thus

(11) Repeat steps (6) through (9) above for contaminating them.
the other arm. (17) Grasp the other end of the towel and
dry your other hand and arm in the same
(12) Discard brush. manner as above. Discard the towel into a
linen receptacle (the circulator may take it
(13) Rinse hands and arms without from the distal end).
retracing and/or contaminating.
Figure 1-13
(14) Allow the water to drip from your
elbows before entering the operating
room.
(15) Slightly bend forward, pick up the hand
towel from the top of the gown pack and
step back from the table (see Figure 1-11).
Grasp the towel and open it so that it is
folded to double thickness lengthwise. Do
not allow the towel to touch any unsterile
object or unsterile parts of your body. Hold Figure 1-14
your hands and arms above your elbow,
and keep your arms away from your body. Figure 1-11

(16) Holding one end of the towel with one

of your hands, dry your other hand and arm
with a blotting, rotating motion (see Figure
References:
1-12).
(Phillips, N.) Berry & Kohn’s Operating Room Technique 11thed. p. 263
Work from your fingertips to the elbow; DO
NOT retrace any area. Dry all sides of the (Hinkle, J.L., et al.,) Brunner & Suddarth’s Textbook of Medical-Surgical Nursing p.419
fingers, the forearm, and the arms
https://brooksidepress.org/Products/Scrub_Gown_and_Glove_Procedures/
thoroughly (see Figures 1-13 and 1-14). If Figure 1-12
moisture is left on your fingers and hands, lesson_1_Section_4.htm
donning the surgical gloves will be difficult.
Moisture left on the arms may seep