ASEPSIS AND INFECTION CONTROL

Terms
Infection
An invasion of the body tissue by
microorganisms and their
proliferation there
Asepsis
The absence of disease-producing
microorganisms Being free from
infection
Medical Asepsis
Practices designed to reduce the
number and transfer of pathogens
Clean technique
Surgical Asepsis
Practices that render and keep
objects and areas free from
microorganisms Sterile technique
Sepsis
The presence of infection
Septicemia
Transport of infection or the products
of infection throughout the body or
by blood
Carrier
A person or animal, who is without
signs of illness but who harbors
pathogens within his body that can
be transferred to another
Contact
A person or animal known or
believed to have been exposed to a
disease
Reservoir
The natural habitat for the growth
and multiplication of
microorganisms
Transient flora or bacteria
The microorganism picked up by the
skin as a result of normal activities
that can be removed readily
Resident flora or bacteria
The microorganism that normally
live on a persons skin

Sterilization
The process by which all
microorganisms including their
spores are destroyed
Disinfectant
A substance, usually intended for use
on inanimate objects, that destroys
pathogens but generally not the
spores
Antiseptic
A substance, usually intended for use
on persons that inhibit the growth of
pathogens but not necessarily destroy
them
Bactericidal
A chemical that kills microorganisms
Bacteriostatic
An agent that prevents bacterial
multiplication but does not kill all
forms of organisms
Contamination
The process by which something is
rendered unclean or unsterile
Disinfection
The process by which pathogens but
not their spores are destroyed from
inanimate objects
Communicable Disease
Results if the infectious agent can be
transmitted to an individual by direct
or indirect contact through a vector
or vehicle, or as an airborne infection
Infectious Disease
Results from the invasion and
multiplication of microorganisms in
a host
Pathogen
A disease-producing microorganism
Pathogenecity
The ability to produce a disease

1
ASEPSIS AND INFECTION CONTROL

Virulence
The vigor with which the organism
can grow and multiply
Specificity
The organisms attraction to a
specific host, which may include
humans
Opportunistic Pathogen
Causes disease only in susceptible
individual
Nosocomial Infection
Hospital-acquired infection

Isolation
The separation of persons with
communicable diseases from other
persons so that their direct/indirect
transmission to susceptible persons is
prevented
Isolation Techniques
Practices designed to prevent the
transfer of specific microorganisms
Etiology
The study of causes

COLONIZATION is the process by which strains of microorganisms become resident

flora.

In this state, the microorganisms may grow and multiply but do not cause disease
Infection occurs when newly introduced or resident microorganisms succeed in
invading a part of the body where the hosts defense mechanisms are ineffective
and the pathogen causes tissue damage.
The infection becomes a disease when the signs and symptoms of the infection are
unique and can be differentiated from other conditions.

INFECTION
is a disease state that results from the presence of pathogen (disease producing
microorganisms) in or on the body
- Occurs as a result of cyclic process, consisting of six components (chain of infection)
TYPES OF INFECTION:
1. LOCAL INFECTION is limited to the specific part of the body where the
microorganisms remain
2. SYSTEMIC INFECTION the microorganisms spread and damage different parts of the
body.
ACUTE INFECTION generally appears suddenly or last a short time
CHRONIC INFECTION may occur slowly, over a long period of time, and may last
months or years

2
ASEPSIS AND INFECTION CONTROL

FOUR TYPES OF MICROORGANISMS CAUSING INFECTIONS:

1. BACTERIA the most common infection causing microorganisms
- several hundred species can cause disease in humans and can live and be transported through
air, water, food, soil, body tissues, and fluids and inanimate objects.
- can be categorized as gram positive or gram negative, based on their reaction to the Gram
stain.
Gram positive have a thick cell wall that resists decolorization and are stained violet
Gram negative have chemically more complex cell walls and can be decolorized by
alcohol
Aerobic require oxygen to live and grow
Anaerobic those that can live without oxygen
2. VIRUS consists primarily of nucleic acid and therefore must enter living cells in order to
reproduce
- common virus families include rhino virus (causes common colds), hepatic,
herpes, and human immunodeficiency virus
- are smallest of all microorganism, visible only with electron microscope
3. FUNGI include yeast and molds
- Plantlike organisms that also cause infection and are present in the air, soil and water
- Examples of infection caused by fungi are athletes foot, ring worm, and yeast infection
- Candida albicans is yeast considered to be a normal flora in the human vagina
4. PARASITES live in other living organisms
- They include protozoa such as the one that causes malaria, helminthes (worms), and
arthropods (mites, fleas, ticks).
STAGES OF INFECTIOUS PROCESS
1. INCUBATION PERIOD
- Extends from the entry of microorganisms into the body to the onset of signs and symptoms
- is the interval between the pathogens invasion of the body and the appearance of symptoms
of infection.
- During this stage, the organisms are growing and multiplying
- the length of incubation may vary, for example, common cold has an incubation period of 1
2 days, whereas tetanus has an incubation period of 2 21 days
2. PRODROMAL PERIOD
- Extends from the onset of non-specific signs and symptoms to the appearance of specific
signs and symptoms
- A person is most infectious during this stage
- Early signs and symptoms of disease are present, but these are often vague and non
specific, ranging from fatigue, malaise to low grade fever
- Last for several hours to several days
3. ILLNESS PERIOD

- Specific signs and symptoms develop and become evident

4. CONVALESCENT PERIOD
- Signs and symptoms start to abate until the client returns to normal state of health
- is the recovery period from the infection
- may vary according to severity of the infection and patients general condition
- The signs and symptoms disappear and the person returns to a healthy state

THE
CHAIN
OF
INFECTI
ON

(1) Etiologic/Infectious Agent:

(6) Susceptible Host

Immunosuppressed children/
elderly, chronically ill, those
with trauma or surgery

(2) Reservoir
(source):
Human beings,
animals,
inanimate objects, plants,
general environment such as air,

(5) Portal of Entry

Mucous membrane, nonintact skin, GI tract, GU tract, Respiratory Tract

(4) Modes of Transmission

Contact, vehicle, airborne, vectorborne

CHAIN OF INFECTION

Six links make up the chain of infection: etiologic agent or

microorganism; the place where the organism naturally resides
(reservoir); a portal of exit from the reservoir; a method (mode) of
transmission; a portal of entry into a host; and the susceptibility of the
host.

1. Etiologic Agent (microorganism)

 These may b e bacteria, virus, fungi or parasites. The ability of the

infectious agent to cause a disease depends on its pathogenecity,
virulence, invasiveness and specificity.
The extent to which any microorganism is capable of producing an
infectious process depends on the number of microorganism present, the
virulence and potency of the microorganisms to enter the body, the
susceptibility of the host and the ability of the microorganisms to live in the
hosts body.
2. Reservoir (source)
o Humans (clients, visitors, health care personnel)
o Animals (insects, rats)
o Plants
o General Environment (air, water, food, soil)
Or sources of microorganisms
People are the most common source of infection for others and for
themselves (e.g. the person with influenza virus frequently spread it to
others.

3.

4.

a.

CARRIER a person or animal reservoir of specific infectious agent

that usually does not manifest any clinical signs of disease.(the
anopheles mosquito reservoir carries the malaria parasite but is
unaffected by it); under either circumstance, the carrier state may be
of short duration (temporary or transient) or long duration (chronic
carrier).
Portal of Exit from Reservoir
Respiratory Tract: droplets, sputum
Gastrointestinal Tract: vomitus, feces, saliva, drainage tubes.
Urinary Tract: urine, urethral catheters.
Reproductive Tract: semen, vaginal discharge
Blood: open wound, needle puncture site
Mode of Transmission
After a microorganism leaves it source or reservoir, it requires a means of
transmission to reach another person or host through a receptive portal of entry
Contact Transmission
This may be direct or indirect contact:

Direct contact
- involves immediate and direct transfer from person to person (body surface to
body surface) through touching, biting, kissing, or sexual intercourse
Indirect
contact
- occurs when susceptible host is exposed to a

- contaminated object such as dressing, needle, surgical instrument

b. Droplet Transmission (direct)
- This may be considered a type of contact transmission.
- It occurs when mucous membrane of the nose, mouth, or conjunctiva are exposed
to secretion of an infected person who is coughing, sneezing, laughing, or talking,
usually within a distance of 3 feet
c. Vehicle Transmission (indirect)
- Vehicle is any substance that serves as an intermediate means to transport
and introduce an infectious agent into a susceptible host through a suitable
portal of entry.
- This involves the transfer of microorganisms by way of vehicles or
contaminated items that transmit pathogens
- Examples: Fomites (inanimate objects or materials) such as handkerchiefs, toys,
soiled clothes, or eating utensils, and surgical instrumentssss or dressings.
- Water, food, blood, serum and plasma are other vehicles (e.g. food or water may
become contaminated by food handler with Hepatitis A virus, the food is then
ingested by a susceptible host.
d. Airborne Transmission
- May involve droplets or dust. Droplet nuclei, the residue of evaporated
droplets emitted by infected host such as someone with tuberculosis, ca
remain in the air for long periods.
- This occurs when fine particles are suspended in the air for a long time or when
dust particles contain pathogens. Air current disperses microorganisms, which
can be inhaled or deposited on the skin of a susceptible host
e. Vector- borne Transmission (indirect)
- Vector is an animal or flying or drawling insect that serves as an intermediate
means of transporting the infectious agent. The transmission may occur by
injecting salivary fluid during biting or depositing feces or other materials on the
skin through the bite wound or a traumatized skin area.
- Vectors can be biologic or mechanical
Biologic vectors are animals, like rats, snails, ,mosquitoes
Mechanical vectors are inanimate objects that are infected with infected
body fluids like contaminated needles and syringes
5. Portal of Entry
a. This permits the organism to gain entrance into the host
b. Pathogens can enter susceptible hosts through body orifices such as the mouth,
nose, ears, eyes, vagina, rectum or urethra. Breaks in the skin or mucous
membranes from wounds or abrasions increase chance for organisms to enter
hosts
6. Susceptible Host

a. A host is a person who is at risk for infection; whose own body defense
mechanisms, when exposed, are unable to withstand the invasion of
pathogens

HUMAN BODY AREA RESERVOIRS, COMMON INFECTIOUS

MICROORGANISMS, AND PORTALS OF
EXIT
BODY AREA
PORTALS OF EXIT
COMMON
RESERVOIR
INFECTIOUS
Nose or mouth through
ORGANISMS
Respiratory tract
sneezing, coughing,
breathing, or talking
Parainfluenza virus
Mycobacterium
Tuberculosis
Gastrointestinal tract Staphylococcus Aureus
Mouth: saliva, vomitus;
feces; ostomies
Hepatitis A virus
Urinary Tract
Reproductive Tract

Blood

Tissue

Salmonella Species
Clostridium difficile
Escherichia coli
enterococci
Pseudomonas
aeroginosa
Neisseria gonorrhoeae
Treponema pallidum
Herpes simplex virus
type 2 Hepatitis B virus
(HBV)
Hepatitis B virus
Human Immunodeficiency
virus (HIV)
Staphylococcus
aureus
Staphylococcus
epidermis

Anus: feces, colostomies

Ureathral meatus and
urinary diversion
Vagina: vaginal
discharge; urinary
meatus; semen; urine

Open wound, needle

puncture site, any disruption
of intact skin or mucous
membrane surfaces

Drainage from cut or wound

BODY DEFENSES AGAINST INFECTION

1. NONSPECIFIC DEFENSES
- protect the person against all microorganisms, regardless of prior exposure
- includes anatomic and physiologic barriers and the inflammatory response
a. Anatomic and Physiologic Barriers
Intact skin and mucous membranes are the bodys first line of defense against
microorganisms.
Resident bacteria of the skin also prevent other bacteria from multiplying.
Normal secretions make the skin slightly acidic; acidity also inhibits bacterial growth
Nasal passages have a defensive function. As entering air follows the tortuous route of
passage, it comes in contact with moist mucous membranes and cilia. These trap
microorganisms, dust, and foreign materials.
The lungs have alveolar macrophages (large phagocytes). Phagocytes are cells that
ingest microorganisms, other cells, and foreign particles.
Each body orifice also has protective mechanisms. The oral cavity regularly sheds
mucosal epithelium to rid the mouth of colonizers. The flow of saliva and its partially
buffering action help prevent infections. Saliva contains microbial inhibitors, such as
lactoferrin, lysozyme, and secretory IgA.
The eye is protected from infection by tears, which continually wash
microorganisms away and contain inhibiting lysozyme.
The gastrointestinal tract also has defenses against infection. The high acidity of the
stomach normally prevents microbial growth. The resident flora of the large intestine
helps prevent the establishment of disease
producing microorganisms. Peristalsis also tends to move microbes out of the body.

The vagina also has natural defenses against infection. When a girl reaches puberty,
lactobacilli ferment sugars in the vaginal secretions, creating a vaginal pH of 3.5 to 4.5.
This low pH inhibits the growth of many disease producing microorganisms. These
include Staphylococcus epidermis coagulase (from the skin) and Escherichia coli (from
feces). It is believed that the urine flow has a flushing and bacteriostatic action that keeps
the bacteria from ascending the urethra. The intact mucosal surface also acts as a barrier.

b. Inflammation
- is a local and nonspecific defensive response of the tissues to an injurious or infectious
agent. It is an adaptive mechanism that destroys or dilutes the injurious agent, prevents
further spread of the injury, and promotes the repair of damaged tissue.
It is characterized by five signs: 1. Pain, 2. Swelling, 3. Redness, 4. Heat, 5.
Impaired function of the part.

1
1

THREE STAGES OF INFLAMMATORY RESPONSE:

1. Vascular and Cellular responses
2. Exudate production
3. Reaparative phase
a. VASCULAR & CELLULAR RESPONSES
At the site of first stage of inflammation, blood vessels at the site of injury
constrict. This rapidly followed by dilation of small blood vessels (occurring as a
result of histamine released by the injured tissues). Thus, more blood flows to
the area. This marked increase in blood supply is referred to as hyperemia and is
responsible for the characteristic signs of redness and heat. Vascular permeability
increases at the site with dilation of the vessels in response to cell death, the
release of chemical mediaotrs (e.g. bradykinin, serotonin, and prostaglandin),
and the release of histamine.
Fluid, proteins and leukocytes (white blood cells) leak into the interstitial
spaces, and the signs of inflammation swelling (edema) appear.
Pain is caused by the pressure of accumulating fluid on nerve endings and the
irritating chemical mediators. Fluid pouring into areas such as the pleural or
pericardial cavity can seriously affect organ function. In other areas, such as joints,
mobility is impaired.
Blood flow slows in the dilated vessels, allowing more leukocytes to arrive at the
injured tissues. When the blood flow slows, leukocytes to aggregate or line up along
this inner surface of the blood vessels. This process is known as margination.
Leukocytes then move through the blood vessel wall into the affected tissue
spaces, a process called emigration.
In response to the exit of leukocytes from the blood, the bone marrow produces large
numbers of leukocytes and releases them into the bloodstream. This is called
leukocytosis. A normal leukocyte count of 4,500 to 11, 000 per cubic millimeter of
blood can rise to 20, 000 or more when inflammation occurs.
b. EXUDATIVE PRODUCTION
In the second stage of inflammation, the inflammatory exudates is produced,
consisting of fluid that escaped from the blood vessels, dead phagocytic cells, and
dead tissue cells and products that they release. The plasma protein fibrinogen (which
is converted to fibrin when it is released into the tissues), thromboplastin (released by
injured tissue cells), and platelets together form an interlacing network to wall off the
area, and prevent spread of the injurious agent. During this stage, the injurious agent
is overcome, and the exudate is cleared away by lymphatic drainage.

1
2

The nature and amount of exudates vary according to the tissue involved and the
intensity and duration of the inflammation. The major types of exudates are serous,
purulent, and hemorrhagic (sanguineous).

c. REPARATIVE PHASE
The third stage of the inflammatory response involves the repair of injured tissues
by regeneration or replacement with fibrous tissues (scar) formation.
Regeneration is the replacement of destroyed tissue cells by cells that are identical or
similar in structure and function.
Damaged cells are replaced one by one but also cells are organized so that the
architectural pattern and function of the tissue are restored. The ability to regenerate
cells varies considerably from one type of tissue to another. For example epithelial
tissues of the skin and of the digestive and respiratory tracts have a good regenerative
capacity, if their underlying support structures are intact.
When regeneration is not possible, repair occurs by fibrous (scar) tissue formation.
The inflammatory exudate with its interlacing network of fibrin provides the
framework for this tissue to develop. Damaged tissues are replaced with the
connective tissue elements of collagen, blood capillaries, lymphatics, and other
tissue bound substances.

In the early stages of this process, the tissue is called granulation tissue. It is a
fragile, gelatinous tissue, appearing pink or red because of the many newly formed
capillaries. Later in the process, the tissue shrinks ( the capillaries are constricted,
or even obliterated) and the collagen fibers contract, so that a firmer fibrous tissue
remains. This is called cicatrix, or scar.

2.SPECIFIC (IMMUNE) DEFENSES

Involve the immune system.
are directed against identifiable bacteria, viruses, fungi, or other infectious agents
An antigen is a substance that induces a state of sensitivity or immune
responsiveness (immunity). If the proteins originate in a persons own body, the
antigen is called auto antigen.
The immune response has two components: 1.) antibody mediated defenses 2.) cell mediated
defenses
a. ANTIBODY MEDIATED DEFENSES
Or Humoral (or circulating) Immunity, these defenses reside ultimately in the B
lymphocytes and are mediated by antibodies produced by B cells.
Antibodies are also called Immunoglobulins, are part of the bodys plasma proteins.
The antibody mediated responses defend primarily against the extracellular
phases of bacterial and viral infections.

1
3

There are two major types of immunity: Active and Passive.

In ACTIVE IMMUNITY, the host produces anibodies in response to natural antigens
(e.g. infectious microorganisms) or artificial antigens (e.g. vaccines). B cells are
activated when they are recognizing the antigen. They then differentiate into plasma
cells, which secrete the antibodies and serum proteins that bind specifically to the
foreign substance and initiate a variety of elimination process. The B cell may produce
antibody molecules of five classes of immunoglobulins designated by letters and
usually written as IgM, IgG, IgA, IgD, and IgE. The presence of IgM in laboratory
analysis shows current infection. Before the antibody response can become effective,
the phagocytic cells of the blood bind and ingest foreign substances. The rate of
binding and phagocytosis increases if IgG antibodies (which indicate past infection
and subsequent immunity) are present.
With PASSIVE IMMUNITY (ACQUIRED), the host receives natural (e.g. from
nursing mother) or artificial (e.g. from an injection of immune serum) antibodies
produced by another source.

b. CELL MEDIATED DEFENSES

Or cellular immunity, occur through T cell system. On exposure to antigen, the
lymphoid tissues release large numbers of activated T cells into the lymph
system. These T cells pass into general circulation.
There are three main groups of T cells: (a) Helper T cells, (b) Cytotoxic T cells, which
attack and kill microorganisms and sometimes the bodys own cells; and (c)
suppressor T cells, which can suppress the functions of the helper T cells and the
cytotoxic T cells.
When cell mediated immunity is lost, as occurs with human immunodeficiency
virus (HIV) infection, an individual is defenseless gainst most viral, bacterial, and
fungal infections.
TYPES OF IMMUNIZATION
1. Active Immunization
- Antibodies are produced by the body in response to infection
a. Natural
- Antibodies are formed in the presence of active infection in the body
- It is lifelong (e.g. recovery from mumps, chicken pox)
b. Artificial
- Antigens (vaccines or toxoids) are administered to stimulate antibody production
- Requires booster inoculation after many years (e.g. tetanus toxoid, oral polio vaccine)
2. Passive Immunization
- Antibodies are produced by another source such as animal or human

1
4

a. Natural
- Antibodies are transferred from the mother to her newborn through the placenta or in the
colostrums
b. Artificial
- Immune serum (antibody) from an animal or another human is injected to a
person. (e.g. tetanus immunoglobulin human (TGIH)).
TYPES OF IMMUNIZATION
TYPE

ANTIGEN OR ANTIBODY SOURCE

DURATION

1. ACTIVE
a. Natural
b. Artificial

Antibodies are produced by the body in response to an antigen

Antibodies are formed in the presence of active infection in the
body
Antigens (vaccines or toxoids) are administered to stimulate
antibody
production

Long
Lifelong

2. PASSIVE
a. Natural
Antibodies are produced by another source, animal or human.
Antibodies are transferred naturally from an immune mother to
babythe placenta or in colostrums
b. Artificial her
through
Immune serum (antibody) from an animal or another human is
injected.

Short
6months to 1
year
2 to 3 weeks

FACTORS INFLUENCING THE HOSTS SUSCEPTIBILITY

Intact skin and mucous membrane are the bodys first line of defense.
The normal ph levels of secretions and of genito-urinary tract help ward off microbial
invasion.
The bodys WBC influence resistance to certain pathogens.
The age sex and race have been shown to influence susceptibility.
Immunization. (natural/acquired), acts to resists infection.
Fatigue, climate, general health status, presence of pre-existing illness,
previous/current treatments and some kinds of medications may play a part in the
susceptibility of a potential host.

PRINCIPLES UNDERLYING MEDICAL AND SURGICAL ASEPSIS

The patient is a source of pathogenic microorganisms.
The patients microorganisms leave through specific routes.

1
5

There are always microorganisms in the environment which in some individuals

and under certain circumstances can cause illness.

1
6

Microorganisms harmful to man can be transmitted by direct and indirect contact.

Spread of infection from source to others can be prevented by various methods to
stop the spread as close to the source as possible.
The effectiveness of medical/surgical asepsis is dependent on the conscientiousness
of those carrying them out.
In observing medical asepsis, areas are considered contaminated if they bear or are
suspected of having pathogens.
In observing surgical asepsis, areas are considered contaminated if touched by any
object that is not sterile.

BREAKING THE CHAIN OF INFECTION: ASEPTIC PRACTICES

Hand washing
Cleaning, Disinfection, Sterilization
Use of Barriers
Isolation Systems
Surgical Asepsis
1. HANDWASHING
Hand washing is the single most important infection control practice. All caregivers,
clients and family members should learn hand washing techniques.
Microorganisms are transient flora until the hands are washed.
Soap and water and alcohol based hand rubs are effective preparations for
removing transient microorganisms.
Wash hands before and after every client care contact.
Effectiveness of hand washing is greatly influenced by adequate friction and
thoroughness of surfaces cleansed.
Hand washing for medical asepsis is done by holding hands lower than the
elbows. Hands are more contaminated that the lower arms.
Wash hands using running water, soap and friction for 15 to 3o seconds on
each hand. This is mechanically loosened and removes dirt and
microorganisms on all hand surfaces.
Clean under fingernails.
Ideally, turn off faucet with clean paper towel.
Keep fingernails short and avoid nail polish to prevent harboring microorganisms.
Always wear gloves during client care when the skin is abraded.
2. CLEANING, DISINFECTION AND STERILIZATION
Cleaning
The physical removal of visible dirt and debris by washing, dusting or mopping
surfaces that are contaminated. Soap is used for mechanical cleaning.
Disinfection
The chemical or physical process used to reduce the number of potential
pathogens on an objects surface. But spores of the pathogens are not necessarily
destroyed.

Sterilization
The complete destruction of all microorganisms, including spores, leaving no viable
forms of organisms.

FACTORS CAN BE CONSIDERED IN THE SELECTION OF

STERILIZATION OR DISINFECTION METHODS:
1. Nature of organisms present
2. Some may be destroyed easily, others more difficult number of organisms
present
more organisms require longer time to destroy organism protected by coagulated protein
requires longer time to destroy
cleaned articles before disinfection or sterilization are rendered clean/sterile more
quickly
3. Types of equipment
Equipment with small lumen, or points are difficult to clean an require special care
4. Intended use of equipment
for medical asepsis: clean technique
for surgical asepsis: sterile technique
5. Available means of sterilization and disinfection
METHODS OF STERILIZATION:
1. Steam sterilization
Autoclaving is sterilization using supersaturated steam under pressure.
This method is non toxic, inexpensive, sporicidal, and able to penetrate fabrics
rapidly. It is used to sterilize surgical dressings, surgical linens, parenteral solutions,
metals and glass objects.
Color indicator strips change color, indicating that sterilization has occurred.
Check packaging for integrity and always check the expiration date to ensure sterility of
the object.
2. Gas Sterilization
Ethylene oxide is a colorless gas that can penetrate
plastic, rubber, cotton and other substances. This is used to sterilize oxygen or
suction gauges, BP apparatus, stethoscopes, catheters.
Articles must be left to release the gas through aeration before they are used.
This type of sterilization is expensive and requires 2 to 5 hours to be accomplished.
Ethylene oxide is toxic to humans
3. Radiation
Ionizing radiation penetrates deeply into objects.
This is used in sterilizing drugs, foods, and other heat sensitive items.
4. Chemicals
These are effective disinfectants
They attack all types of microorganisms, act rapidly, work with water, are
inexpensive, are stable in light and heat, are not harmful to body tissues, do not
destroy articles.

These are used for instruments and equipment such as glass thermometer.
Chlorine is used for disinfecting water.
5. Boiling Water
This is least expensive for use in home.
Items like glass baby bottles should be boiled for at least 15 minutes.
TYPES OF DISINFECTION
1. Concurrent Disinfection
in the care of the client, his supplies, his immediate environment, to limit/Ongoing
practices that are observed control the spread of microorganism
2. Terminal Disinfection
Practices to remove pathogens from the clients belongings and his immediate
environment after his illness is no longer communicable
MEDICAL ASEPTIC PRACTICES TO BE IMPLEMENTED DURING CLIENT
CARE
Wash hands frequently, especially:
before handling foods
before and after using the toilet
before and after performing nursing procedures
before and after each patient contact
Keep soiled items/equipment from touching the clothing's.
Instruct client to cover mouth and nose when coughing and sneezing.
Avoid raising dust; do not shake linens
Clean least contaminated areas first then move to more contaminated areas.
Practice segregation of wastes.
Sterilize objects suspected of containing pathogens.
Use practices of good personal hygiene to help prevent spread of microorganisms.
3. USE OF BARRIERS
Techniques that prevent the transfer of pathogens from one person to another are
referred to as barriers.
The most commonly used barriers are as follows:
Masks
Caps and shoe coverings
Gloves
Private rooms
Waterproof disposable bags for linen and thrash
Labeling and bagging of contaminated equipment and specimens
Control of airflow into the sterile areas and out of contaminated areas
Goggles or face shield.
Masks
Masks should fit tightly to the face, covering the nose and the mouth.

 Masks lose their effectiveness if they are wet, worn for long periods, and when they
are not changed after caring for each client.
Disposable particulate respirators look like masks but fit the face more tightly and are
able to filter out particles or organisms as small as 1 micro millimeter. These are
indicated whenever a caregiver is working with a client who has, or is suspected of
having contagious airborne diseases such as tuberculosis.
Gowns
Gowns should be worn when caregivers clothing is likely to be soiled by infected
material.
Use gowns only once and discard them.
Change gowns when it becomes wet.
Caps and Shoe Coverings
Caps are used to cover the hair, and special covers are available for shoes.
These shield body parts from accidental exposure to contaminated body secretions.

Gloves
Gloves protect the hands for acquiring infective organisms.
These reduce likelihood of transmission of microbial flora from personnel to clients or
from client to other clients.
Gloves should be changed and discarded between clients or when they become torn or
grossly soiled.
Hands are washed and dried before and after removing gloves.
Gloves should not be washed and reused.
*Note: Never touch with bare hands anything that is wet coming from a body surface.
Private Rooms
Separation of clients into private rooms decreases the chance of transmission of infection
by all routes.
If this is impossible, a client with an infection may be placed in the same room as
another client who is infected with the same microorganisms, as long as they are not
infected with other potentially transmissible microorganisms and the likelihood of
reinfection with the same microorganisms is minimal.
If transport to another department is necessary, clients gowns and dressings should be
changed before leaving the room and the client should wear necessary barriers such as
mask or gown.

Equipment and Refuse Handling

Articles and linens soiled by any body fluid should be placed in impervious (water
proof) bags before they are removed from the clients bedside.
The outside of the bag should not be contaminated when placing articles inside it; if the
outside of the bag becomes contaminated, placing that bag in another bag (double
bagging is required.
Waste segregation and disposal should ensure prevention of transfer of
microorganisms,
Categories of institutional wastes are as follows:
a. Infectious Waste
- Blood and blood products
- Pathology laboratory specimen
-Laboratory cultures
- Body parts from surgery
- contaminated equipment (suction catheters, urinary catheters, nasogastric tubes)
- Food
- unrinsed infant and adult diapers
b. Injurious Waste
- Needles
- scalpel blades
- Lancets
- Broken glass
- Pipettes

c. Hazardous Waste
- Radioactive materials
-chemotherapy solutions and their containers and other caustic chemicals
Recommendations for waste disposal are as follows: incineration or autoclaving of
infectious wastes before disposal in sanitary landfill; liquid body fluids (blood, urine,
aspirated body fluids) can be flushed down a drain connected to a sewer system; use
separate containers, clearly marked Biohazard, for infectious waste, such as blood
contaminated items.
Most healthcare agencies use color code for segregation of waste:
BLACK trashcan - for wet; biodegradable items
YELLOW trashcan for dry, non biodegradable/ recyclable items.
4. ISOLATION SYSTEMS
ISOLATION refers to techniques used to prevent or to limit the spread of infection.
Isolation precautions are classified as: Standard precautions, Transmission
based precautions, and Protective isolation.
1. STANDARD PRECAUTIONS
Synthesize the major features of Universal Precautions and Body substance
Isolation.
These precautions are intended to prevent transmission of blood borne and
moist body substance pathogens.
A. Wear clean gloves when touching
Blood, body fluids, secretions and excretions, and items containing these body
substances.
Mucous membrane
Nonintact skin
B. Perform hand washing immediately
When there is direct contact with blood, body fluids, secretions and excretions, or
contaminated items.
After removing gloves.
Between patient contacts.
C. Wear a mask, eye protection and face shield during procedures and patient care activities
that are likely to generate splashes or sprays of blood, body fluids, secretions, and
excretions.
D. Wear a cover gown during procedures and patient care activities that are likely to generate
splashes or sprays of blood, body fluids, secretions or excretions, or cause soiling of clothing.
E. Remove soiled protective items promptly when the potential for contact with reservoir of
pathogens is no longer present.
F.Clean and reprocess all equipment before reuse by another patient.

G. Discard all single use items promptly in appropriate containers that prevent contact with
blood, body fluids, secretions and excretions, contamination of clothing, or transfer to other
patients and the environment.
H. Prevent injuries with used needles, scalpels, and other sharp devices by:
Never removing, recapping, bending or
breaking used needles. Note: never recap
needles. Use your needle disposal container.
Never pointing needle toward a body part.
Using a one handed scoop method, special syringes with a retractable protective
guard or shield for enclosing a needle, or blunt point needles.
Depositing disposable and reusable syringes and needles in puncture resistant
containers.
I. Use a private room or consult with an infection control professional for the care of the
patients who contaminate the environment or who cannot or do not assist with
appropriate hygiene or environmental cleanliness measures.
2. TRANSMISSION BASED PRECAUTIONS
A. Airborne Precautions these are used for microorganisms transmitted by small particle
droplets that can remain suspended and become widely dispersed by air currents.
Examples: TB, Varicella, measles(rubeola)
The client should be cared for in a private, negative airflow room, to contain the air
within the clients unit.
Caregivers are to wear masks; the client should wear mask when transported out of
the room.
B. Droplet Precautions these are used for microorganisms transmitted by large particle
droplets, (through coughing, sneezing or talking) which disperse into air currents.
Examples: Haemophilus, influenza, diphtheria, rubella, mumps, mycoplasma pneumonia,
pertussis, streptococcal pharyngitis, or scarlet fever in infants and young children.
The client should be in private room.
The caregivers are to wear masks when working within 3 feet of the client.
The client should wear mask when outside the room.
Limit movement of client outside the room to essential purposes. Place surgical
mask on the client during transport.
C. Contact Precautions these are used with organisms that can be transmitted by hand or
skin to skin contact, such as during client care activities or when touching the clients
environmental surfaces or care items. Examples: clostridium difficile, shigella, impetigo,
wound infections.
The client is cared for in a private room or has a roommate who is infected with
the same organism (cohabitation).
Personnel use gloves before entering the room and change gloves when exposed to
potentially infected material during care delivery.
Remove gloves before leaving the clients room.
3. PROTECTIVE ISOLATION

Implemented to prevent infection for people whose resistance to infection/ body

defenses are lowered or compromised. Examples: clients with low WBC count
(leucopenia); on immunosuppressive medications like cancer chemotherapy; with
extensive burns.
The client should be placed in a private room.
Meticulous hand washing is strictly practiced by the client, his family, and all
caregivers.
Restrict visitors.
Persons with signs and symptoms of infection are not allowed to visit the client.
Examples: those with cough and colds, diarrhea, skin infections.
No fresh fruits or vegetables, raw foods, fresh flowers, potted plants are allowed.
Only cooked or canned fruits are allowed.
SURGICAL ASEPSIS
The purpose of sterile technique is to prevent the introduction of microorganisms.
Surgical asepsis is required in the following situations:
Surgical procedures
All procedures that invade the bloodstream
Procedures that cause a break in skin or mucous membranes (e.g.
intramuscular injections).
Complex dressing changes and wound care.
Insertion of tubes, catheters or devices into sterile body cavities (e.g. urinary
bladder).
Care for high risk groups (e.g. transplant recipients, burn clients, clients with
cancer).

PRINCIPLES OF SURGICAL ASEPSIS

1. Moisture causes contamination.
Prevent splashing of liquids in the sterile fields.
Place wet objects on sterile, water impermeable surfaces, such as sterile basin.
Rationale: Microorganisms travel more easily through moist environment. When sterile
surface becomes moist, microorganisms from the unsterile surface may be transmitted
into the sterile surface.
2. Never assume that an object is sterile.
Ensure that it is labeled as sterile.
Always check the integrity of the packaging.
Always verify the expiration date on the package.
Whenever in doubt of the sterility of an object, consider it unsterile.
Rationale: Commercially prepared products are labeled as sterile on their
packaging.
Special indicators are used to show that objects have completed their
sterilization process,
Packages that are torn, punctured, or moist are considered unsterile.

An object is considered sterile only for a specified period. Items that have
passed the expiration date are considered unsterile.
3. Always face the sterile field.
Rationale: Objects are out of the line of vision may be inadvertently contaminated.
4. Sterile articles may touch only sterile articles or surfaces if they are to maintain their
sterility.
Rationale: Anything considered unsterile may transfer microorganisms to the sterile
object it touches. An object used in cleaning the skin (e.g. swabs) must be used once and
then discarded because the skin cannot be sterilized.
5. Sterile equipment or areas must be kept above the waist and on top of the sterile field.
Drapes hanging over the edge of the table are not considered sterile.
Rationale: Waist level is the limit of good visual field. Maximum visibility of all
sterile objects prevents inadvertent contamination.
6. Prevent unnecessary traffic and air currents around the sterile area.
Close doors.
Unfold drapes or wrappers slowly.
Do not sneeze, cough, or talk excessively over the sterile field.
Do not reach across sterile fields.
Move around a sterile field to reach for an
object, if necessary. Rationale:
Microorganisms cannot be completely excluded from the air.
Overreaching across sterile fields will render sterile objects unsterile.
7. Open, unused sterile articles are no longer
sterile after the procedure. Rationale:
Once protective wrapping have been removed, the article is being contaminated
by air so, it must be discarded or desterilized before it is used.
Liquids opened during the procedure that remain in their original container
are also considered contaminated.
8. A person who is considered sterile who becomes contaminated
must reestablish sterility. Rationale:
If a scrubbed person punctures the gloves or is contaminated by touching
an unsterile object, he or she must change the contaminated article.
If a scrubbed person leaves the area of the sterile field, he or she
must go through the procedure of rescrubbing, gowning and gloving.
9. Surgical technique is a team effort.
A collective and individual sterile conscience is the best method of enhancing
sterile technique. Rationale:
Staff members must rely on one another to maintain sterile technique.
Periodic review of procedures and infection control surveillance reports
enhance everyones sterile technique.

PERFORMING NURSING SKILLS

PERFORMING STERILE PROCEDURES:
Surgical Hand Scrub
Applying and Removing Sterile Gloves
Donning Sterile Gown and Closed Gloving
Donning and Removing Caps, Masks, and Eyewear
Preparing and Maintaining A Sterile Field
Opening Sterile Drape
Adding Sterile Supplies to the Field (Opening Sterile packages, opening a sterile item on a Flat
surface)
Pouring Sterile Solutions
Care of Sterile Pick up Forceps
SURGICAL HAND SCRUB
PURPOSE: Remove as many microorganisms from the hands as possible before the
sterile procedure EQUIPMENT:
Sink with a knee or foot controls
Antimicrobial soap
Surgical scrub brush
Plastic nail stick or sterile nail cleaner (ideally)
Sterile towel for drying
STEPS:
1. Be sure fingernails are short, clean, and healthy. Nail polish
should be removed. Rationale: Long nails and nail polish
increase number of bacteria residing on nails.
2. Remove rings. Apply surgical shoe covers, cap, face mask, and protective eye wear.
Rationale: rings can harbor microorganisms. Applying attire after hand washing would
contaminate hands.
3. Wash and rinse hands for initial wash.
Rationale: To remove gross contamination and transient microorganisms.
4. Open disposable brush impregnated with microbial soap, adjust water temperature to warm
using knee or foot control lever.
Rationale: Antimicrobial soap reduces microorganisms. Warm water decreases drying hands.
5. Wet hands and arms. Keep hands above elbows.
Rationale: Movement of water and dirt will flow from hands to less clean areas; thus,
preventing contamination of the hands during scrub.
6. Use nail stuck or cleaner to clean under nails of both hands.
Rationale: The nails can harbor significant bacteria and need to be cleaned thoroughly.

26
ASEPSIS AND INFECTION CONTROL

7. Wet scrub brush or apply antimicrobial soap if not already

impregnated in the brush. Rationale: Antibacterial soap assists in
removing transient and resident microorganisms.
8. Anatomic timed Scrub. Starting with fingertips, scrub each anatomic area (nails, fingers
each side and web space, palmar surface, dorsal surface and forearm) for around 5 minutes.
Scrub vigorously using vertical strokes. Repeat with other hand.
Rationale: Ensures that all surfaces will be systematically scrubbed to remove
transient and resident microorganisms.
9. Counted Brush Stroke Method. Starting with fingertips, scrub each anatomic area (same as
no. 8) for the designated number of strokes according to agency policy. Scrub vigorously
using vertical strokes. Rationale: Same as in no.
8.Rinse hands thoroughly under warm running water, holding hands upward. This is to
allow water to drain towards the flexed elbows.
Rationale: Prevents contamination of the hands from dirtier areas.
Note: Do not touch anything before and after rinsing hands. Touching nonsterile
objects would mean the surgical scrub would need to be repeated.
10. Keep hands held upward to allow water to drip from the hands to the elbow. Dry hands
with sterile towel. Rationale: Prevents contamination before gloving.
APPLYING AND REMOVING STERILE GLOVES
Purpose: Prevent transfer
of microorganisms
Equipment:

Packaged sterile gloves in correct size

Flat working surface

Steps:
a. Applying Gloves
1. Wash hands.
Rationale: Clean hands reduce the number of microorganisms that could be transmitted if
gloves accidentally puncture or tear.
2. Peel off outside wrapper as directed by manufacturer (peel sides apart).
Rationale: This protects inner package from inadvertently opening and contaminating the
gloves.
3. Lay inner package on clean, flat surface about waist level. Open wrapper from the outside,
keeping gloves on inside surface.
27
ASEPSIS AND INFECTION CONTROL

Rationale: Objects below waist level are considered contaminated. Inner surface of
wrapper is considered sterile.
4. Grasp first glove by inside edge of cuff with thumb and first two fingers of the dominant
hand. Hold hands above waist; insert non dominant hand into glove. Adjust fingers inside
glove after both gloves are on. Rationale: Objects below waist level are considered
contaminated. Inner surface of wrapper is considered sterile.
5. Grasp first glove by inside edge of cuff with thumb and first two fingers of the dominant hand.
Hold hands above waist; insert non dominant hand into glove. Adjust fingers inside glove
after both gloves are on. Rationale: Inner folds of cuff unfold against skin of hand and are not
sterile once applied. Contamination occurs if ungloved hand contacts gloved hand.
6. Slip gloved hand (four fingers with thumb up) underneath second gloved cuff and pull over
dominant hand. Rationale: Sterile cuff protects fingers of gloved hand from being
contaminated.
Note: Put on gloves on the nondominant hand first, then on the dominant hand.
7. Keeping hands above waist, adjust glove fit, touching only sterile areas.
Rationale: This prevents potential contamination while ensuring a smooth fit over fingers.
B. Removing Gloves
8. Wash gloved hands first.
Rationale: To reduce the number of microorganisms that could contaminate the hands.
9. With dominant hand, grasp outer surface of non dominant glove just below thumb. Peel off
glove inside out, without touching exposed wrist. Rationale: After use, outer surface of
gloves is contaminated and could transfer microorganisms to the nurses wrist.
10. Place ungloved hand under thumb side of second cuff and peel off toward the fingers
holding first glove inside second glove. Discard into appropriate receptacle.
Rationale: folding contaminated glove surfaces toward the inside minimize the
chance of transfer of microorganisms.
Note: Use glove to glove, skin to skin technique when removing gloves.
11. Wash hands.
Safety Alert: Wash hands before and after removing gloves to prevent contamination of
hands.
DONNING A STERILE GOWN AND CLOSED GLOVING
Purpose: To apply attire necessary to safely carry out sterile procedures usually in the
operating room and delivery room.
Equipment:
Sterile gown
Sterile Gloves
Mayo stand or flat surface area above waist level
Steps:
28
ASEPSIS AND INFECTION CONTROL

1. Wear shoe covers, cap that covers all hair, face mask and protective eye wear (ideally) and
perform surgical scrub.
Rationale: The gown and gloves should be donned last, because it is the most important for
them to be sterile.
a. DONNING A STERILE GOWN
2. Grasp folded sterile gown at the neckline and step away from the sterile field. Allow gown
to gently unfold, being careful that it does not touch the floor. The inside of the gown is
toward the user.
Rationale: Maintains sterility of the gown and positions it for donning.
3. Holding the arms at shoulder level, grasp the sterile gown just below the neckband near
the shoulders and slide arms in the sleeves until the fingers are at the end of the cuffs but
not through the cuffs.
Rationale: the fingers remain in the cuffs to protect the sterility of the gown and prepare for
closed gloving.
4. Have someone tie the back of the gown, taking care that only the ties are touched and not the
sides or front of the gown.
Rationale: Maintains sterility of the gown. Gowns are considered sterile in the front from
the shoulder to the table level, and sleeves are considered sterile from 2 inches above the
elbow to the wrist.
b. CLOSED GLOVING
5. With fingers still within the cuff of the gown, open the inner sterile glove package and pick
up the first glove by the cuff, using the nondominant hand.
Rationale: Maintains sterility of the glove.
6. Position the glove over the cuff of the gown so the fingers are in alignment, and stretch the
entire glove glove over the cuff of the gown, being careful not to touch its edge. Fingers
remain within the cuff of the gown. Rationale: Maintains sterility of the glove.
7. Work the fingers into the glove and pull the glove up over wrist with the non dominant hand
that still remains within the cuff of the gown.
Rationale: Maintains sterility of the glove. Use the sterile gloved hand to pick up the second
glove, placing it over the cuff of the gown of the other hand and repeat the glove application
process.
Rationale: Maintains sterility of the glove.
8. Adjust gloves for comfort and fit, taking care to keep gloved hands above waist
level at all times. Rationale: If gloved hands fall below waist level, they are no
longer sterile.
DONNING AND REMOVING GLOVES, MASKS, GOWNS, AND EYEWEAR
29
ASEPSIS AND INFECTION CONTROL

For sterile procedures on a general nursing division, the nurse may wear surgical
mask and gloves without a cap. Eyewear is ideally worn if there is risk of fluid or
blood splashing into the nurses eyes.
For sterile surgical procedures, the nurse first applies a clean cap that covers all of
the hair and then surgical mask, eye wear, and shoe cover.
A mask must fit snugly around the face and nose to prevent contamination by droplet
nuclei.
To remove protective devices: remove gloves first, then the mask,
The gown, the eye wear or goggles, cap and shoe cover. Removing the
gloves first prevents contamination of the hair, neck, and facial area.

For removing protective wear, do:

Gloves -> Mask -> Gown-> other devices sequence
PREPARING AND MAINTAINING A STERILE FIELD
Purpose: To create an environment that helps ensure the sterility of supplies and equipment
and prevent transfer of microorganisms during sterile procedure.
Equipment:
Flat work surface
Sterile Drape
Sterile Supplies e.g. sterile gauze, sterile basin, solutions, scissors, forceps
Packaged sterile gloves
Steps:
a. Special Considerations
1. Wash hands.
Rationale: Minimizes the number of transient bacteria on the hands.
2. Inspect all sterile packages for package integrity, contamination, or moisture.
Rationale: Moisture, breaks in package integrity, and visible contamination indicate that
the contents are no longer sterile and must be discarded.
3. During the entire procedure, never turn back on the sterile field or lower hands below the
level of the field. Rationale: Ensures sterility of the field.
b. OPENING A STERILE DRAPE
4. Remove the sterile drape from the outer wrapper and place the inner drape in the surface of
the work surface, at or above waist level, with the outer flap facing away from you.
Rationale: Maintains sterility of the package and allows for opening the drape in a
manner that will not contaminate the sterile field.

30
ASEPSIS AND INFECTION CONTROL

5. Touching the outside of the flap, reach around (rather than over) the sterile field to open the
flap away from you. Rationale: Maintains sterility of the field.
6. Open the side flaps in the same manner, using the right hand for the right flap and the left
hand for the left flap.
Rationale: This maintains sterility by avoiding crossing over the field.
7. Open the innermost flap that faces you, being careful that it does not touch your clothing
or any object. Rationale: Maintains sterility of the field.
c. ADDING STERILE SUPPLIES TO THE FIELD
8. Open unsealed edge of prepackaged supplies, taking care not to touch the supplies
with the hands. Rationale: Maintains sterility of the supplies.
9. Hold supplies 10 12 inches above the field and allow them to fall to the middle of
the sterile field. Rationale: Ensures that sterile supplies are placed within the sterile
field.
10. Wrapped sterile supplies are added by holding the sterile object with one hand and
unwrapping the flaps with the other hand. Carefully drop the object onto the sterile field.
Rationale: Maintains sterility of the object and the field.
d. POURING SOLUTIONS TO A STERILE FIELD
11. Check the label and expiration date of the solution. Note any signs
of contamination. Rationale: Ensures that the correct solution is used
and that it is sterile.
12. Remove cap and place it with the inside facing up on a flat surface. Do not touch
inside of cap or rim of bottle.
Rationale: Maintains sterility of the solution and the field.
13. Pour a small amount of solution into a sink or waste container to rinse the rim of the
container (this is done when pouring weak solutions like sterile normal saline solution,
distilled water).
Rationale: This ensures sterility of the solution.
14. Hold bottle 6 inches above receptacle on the sterile field and pour slowly to
avoid spills. Rationale: Spilling fluid on the sterile field results in
contamination because a wet surface allows microorganisms to transfer from
the flat surface which is not sterile.
15. Recap the solution bottle, place it outside the sterile field and label it with date and
time of opening if the solution is to be reused.
Rationale: Keeps solution in the bottle sterile and avoids use of solution that has passed
expiration date.

31
ASEPSIS AND INFECTION CONTROL

16. Add any additional supplies and don sterile gloves before starting the procedure.
Rationale: Donning sterile gloves just prior to beginning the procedure helps to ensure
sterility.

32
ASEPSIS AND INFECTION CONTROL

CARE OF THE STERILE PICK UP FORCEPS

Purpose:
To transfer sterile articles and maintain sterility of these articles and the sterile field.
Equipment:
Sterile forceps in a sterile bottle with germicidal/ disinfectant solution.
Steps:
1. The prongs of sterile forceps should fully immerse in disinfectant solution.
Rationale: this maintains sterility of the part of the forceps that will keep in touch with sterile
objects.
2. Sterile forceps are always held above and in front of the waist, within the
vision of the nurse. Rationale: to prevent inadvertent contamination out of
nurses range vision.
3. The tips of the forceps are always considered sterile and need to be held down.
Rationale: This prevents the fluid from flowing from the sterile tips to the unsterile
handles, becoming contaminated, and then flowing back by gravity to the tips when
they are held down again.
4. The handles of the forceps are considered contaminated except when handled
by sterile gloves. Rationale: Handles of the sterile forceps when held by the
bare hands are considered non sterile.
5. Use the thumb and middle fingers when lifting the forceps from the container. The tip
should not touch the rim or any part of the container not directly in contact with the
disinfectant.
Rationale: The rim and any part of the container not immersed in disinfectant are considered
non sterile. Sterile object should touch only sterile objects or surface.
6. Tap the handle of the forceps with the index finger to remove excess solution from the tip,
outside the sterile field.
Rationale: To prevent the solution from flowing to the handles, then back to the tips of the
forceps. This will prevent contamination of the sterile tips of the forceps.
7. When removing sterile items from a container, the tips of the forceps and / or the item
should be kept away from the edges of the container or disposable wrapper.
Rationale: The edges are exposed to air and are considered contaminated.

33
ASEPSIS AND INFECTION CONTROL

8. Return forceps to the container, without touching the tips to the rim or part of the container
not immersed in disinfectant.
Rationale: This maintains sterility of the forceps.

34
ASEPSIS AND INFECTION CONTROL