Figure 1

Cleaning under fingernails. (From Perry, A.G., Potter P.A. [2010]. Clinical nursing skills &
techniques [7th ed.]. St. Louis: Mosby.)

Figure 2

Scrubbing sides of fingers. (From Perry, A.G., Potter P.A. [2010]. Clinical nursing skills &
techniques [7th ed.]. St. Louis: Mosby.)

Figure 3

Scrubbing forearms. (From Perry, A.G., Potter P.A. [2010]. Clinical nursing skills & techniques [7th
ed.]. St. Louis: Mosby.)
Figure 4

Rinsing arms. (From Perry, A.G., Potter P.A. [2010]. Clinical nursing skills & techniques [7th ed.]. St.
Louis: Mosby.)
Figure 5

Grasping sterile towel. (From Perry, A.G., Potter P.A. [2010]. Clinical nursing skills & techniques [7th
ed.]. St. Louis: Mosby.)
Figure 6

Drying hands thoroughly. (From Perry, A.G., Potter P.A. [2010]. Clinical nursing skills &
techniques [7th ed.]. St. Louis: Mosby.)
Figure 7

Application of antimicrobial agent for brushless hand scrub. (Photo Courtesy of 3M Health Care.)

Figure 8

Rub thoroughly until completely dry. (Photo Courtesy of 3M Health Care.)

ALERT

Hand washing is the number one way to decrease nosocomial infection.

OVERVIEW

In the operating room setting, it is imperative that surgical hand antisepsis is achieved through effective surgical scrub or
antiseptic hand rub. 3 To reduce the risk for patients' acquiring postoperative infections, use of an antimicrobial preparation for
hand antisepsis is an integral part of the presurgical scrubbing procedure for operating room personnel. Although the skin
cannot be sterilized, the number of microorganisms can be greatly reduced by chemical, physical, and mechanical means.

The surgical hand scrub has been the traditional method for surgical asepsis. Through the use of an antimicrobial agent and
sterile brushes or sponges, the surgical hand scrub removes debris and transient microorganisms from the nails, hands, and
forearms; reduces the resident microbial count to a minimum; and inhibits rapid/rebound growth of microorganisms. 1 New
evidence suggests that a brushless technique, with or without water, using an agent containing at least 60% alcohol, is a
valid alternative to the traditional hand scrub with a brush and achieves the same microbial efficacy. 1 If hands are visibly
soiled or if exposure to spore-forming pathogens (such as C. difficile) is suspected, use soap and water. 1 Both hand
antiseptic methods are currently used in operating room settings. This skill addresses both techniques.

Fingernails should be kept short (¼ inch long), clean, and healthy. Fingernail polish should be avoided. If nail polish is worn,
make sure it is not chipped or older than 4 days. Never wear artificial nails or extenders. 1 Remove all rings, watches, and
bracelets before the surgical scrub.

The Association of periOperative Registered Nurses (AORN) recommends a 3- to 4-minute hand and arm scrub with an
approved antimicrobial agent for all surgical procedures. The institution should standardize the surgical hand scrub procedure
for all staff using either the anatomic timed scrub or the counted stroke method (see institutional policy). 1 Some procedures,
described as clean procedures (e.g., laryngoscopy and proctoscopy), require performing hand hygiene but not necessarily
surgical hand antisepsis.

SUPPLIES

Click here for a list of supplies.

PATIENT AND FAMILY EDUCATION

 Instruct patient and family member or significant other to observe surgical site for signs of infection.

ASSESSMENT AND PREPARATION

Preparation 1

1. Determine type and length of time for hand hygiene per institutional policy.
2. Remove bracelets, rings, and watches.
3. Inspect fingernails, which must be short (¼ inch), clean, and healthy. Avoid fingernail polish.
4. Remove artificial nails or extenders.
5. Only use hand lotions that are institution approved. Some lotions can cause the breakdown of gloves.
6. Inspect condition of cuticles, hands, and forearms for presence of abrasions, cuts, or open lesions.

PROCEDURE

1. Apply surgical shoe covers, cap or hood, face mask, and protective eyewear.
Rationale: Prevents contamination of hands after scrub.
2. Perform a prescrub wash at beginning of work shift.
a. Turn water on using foot or knee control, and adjust to comfortable temperature.
b. Wet hands thoroughly with water.
c. Follow manufacturer's directions for application of soap.
 d. Rub hands, covering all surfaces, including the backs of hands, fingertips, inner webs, and palms,
washing for at least 15 seconds.
Rationale: A short prescrub wash/rinse of at least 15 seconds at the beginning of the work shift removes gross
debris and superficial microorganisms.
e. Rinse well to remove all soap.
f. Dry hands thoroughly with a disposable towel and discard towel.
Surgical Hand Scrub (with sponge)

1. Turn on water using foot or knee control.

2. Clean under nails of both hands using a disposable nail pick or cleaner ( Figure 1).
3. Rinse hands and forearms under running water.
4. Dispense the antimicrobial scrub agent according to manufacturer's instructions.
5. Apply agent to wet hands and forearms using a soft, nonabrasive sponge.
Rationale: Ensures removal of resident microorganisms on all surfaces of hands and arms. 3
6. Time a 3- to 5-minute scrub (follow manufacturer's instructions).
a. Visualize each finger, hand, and arm as having four sides (Figure 2).
b. Wash all four sides effectively, keeping the hand elevated, elbow down. Repeat for other hand, fingers,
and arm (Figure 3). Scrubbing time will vary by product.
Rationale: Scrubbing all surfaces ensures removal of resident microorganisms on hands and arms. 3
Avoid splashing surgical attire.
7. Discard sponges in appropriate container.
8. Rinse hands and arms, running water from fingertips to elbows in one continuous motion ( Figure 4).
Rationale: Hands remain cleanest part of upper extremities.
9. Turn off water using foot or knee controls, and back into operating room holding hands higher than elbows and
away from surgical attire.
10. Approach sterile setup and grasp sterile towel, taking care not to drip water on the sterile field ( Figure 5).
Rationale: Water contaminates the field.
11. Keeping hands and arms above the waist and outstretched, carefully grasp one end of the sterile towel to dry one
hand thoroughly, moving from fingers to elbow in a rotating motion ( Figure 6).
Rationale: Avoids sterile towel contact with unsterile scrub attire and the transferring of contamination to hands. Dry
skin from cleanest (hands) to least clean (elbows).
12. Use the opposite end of the towel to dry the other hand.
Rationale: Avoids transfer of microorganisms from elbow to opposite hand.
13. Drop towel into linen hamper or into circulating nurse's hand.
Spongeless Surgical Hand Scrub with an Alcohol-Based Hand-Rub Product

1. After prescrub wash, turn on water using foot or knee control.

2. Clean under nails of both hands using a disposable nail pick or cleaner.
3. Rinse hands and forearms under running water.
4. Dry hands thoroughly with a paper towel.
5. Turn off water.
6. Dispense the manufacturer's recommended amount of the antimicrobial agent hand preparation ( Figure 7). Apply
the agent to the hands and forearms according to manufacturer's instructions for application, recommended volume,
and specified time.
Rationale: Promotes reduction of microorganisms on all surfaces of hands and arms. 3
7. Repeat the antimicrobial product application if indicated in manufacturer's instructions.
8. Rub thoroughly until completely dry (Figure 8).

MONITORING AND CARE

1. Monitor patient postoperatively for signs of surgical wound infection (usually occurs 2 to 3 days postoperatively).
Signs of infection include redness, heat, swelling, pain, and purulent drainage.

EXPECTED OUTCOMES

 Patient does not develop signs of surgical wound infection.

UNEXPECTED OUTCOMES
  Redness, heat, swelling, pain, or purulent drainage develops at surgical site, which often indicates a wound
infection.

DOCUMENTATION

The performance of surgical hand antisepsis may need to be documented as part of operative note or check list of procedure.

 Area of surgical site postoperatively

 Description of surgical site postoperatively
 Patient and family education

REFERENCES

1. Association of periOperative Registered Nurses (AORN). (2011). Recommended practices for hand hygiene in
perioperative setting. In AORN perioperative standards and recommended practice . Denver: Author.
2. Boyce, J.M., Pittet, D. (2002). Guideline for hand hygiene in health-care settings: recommendations of the
Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task
Force. American Journal of Infection Control 30 (8):S1.
3. WHO Guidelines on hand hygiene in health care, Section 13 pages 54-60 (website):
http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf. Accessed February 21, 2010.

ADDITIONAL READING

Joint Commission, The. (2011). Accreditation program: Hospital national patient safety goals . Retrieved on June 8, 2011, from
http://www.jointcommission.org/assets/1/6/2011_NPSGs_HAP.pdf

*In these nursing skills, a "classic" reference is a widely cited, standard work of established excellence that significantly
affects nursing practice and may also represent the foundational research for practice.

Excerpted and adapted from Perry AG, Potter PA: Clinical nursing skills & techniques , ed 7, St. Louis, 2010, Mosby.