The Surgical Scrub, Gowning and Gloving

This is Unit Seventeen of Tech in Surgery Prep. Unit Sixteen ended with a routine case and its three uneventful pauses. This unit goes back to the moment the scrub person becomes sterile: the scrub, the gown and the gloves. Carry one idea through this lecture. Scrubbing, gowning and gloving follow a fixed order, so nothing has to be touched once the hands are prepared, and every slip is said aloud. A worked example near the end follows a student's first scrub, slip and all. Your facility's procedure decides the details; practise them under supervision. By the end you will be able to explain what the scrub does and prepare for it. To perform hand antisepsis by either method. To gown and glove in the right order. And to handle tears, remove gown and gloves, and protect face and skin.

Three entries on what the surgical scrub does, and what must happen before it begins.

More than handwashing.

TSC 401 Scrubbing Is Not Handwashing

Surgical hand preparation removes transient flora and reduces resident flora on the hands and forearms. It also slows bacterial regrowth under sterile gloves, which matters most if a glove is punctured unnoticed. Ordinary handwashing does not substitute for the surgical scrub before joining the field.

What goes on first.

TSC 402 Before You Scrub

Before the scrub, the head covering, mask and eye protection go on, because they cannot be adjusted afterwards. Hands should be clean on entering the operating area, and the mask checked over nose and mouth. Once the scrub begins, scrubbed hands touch nothing unsterile.

Nails and jewelry.

TSC 403 Nails, Jewelry and Skin

Nails are short, and all jewelry, artificial nails and polish are removed before hand preparation. Visibly soiled hands are washed first, with debris cleared from under the nails by a nail cleaner, not a brush. Rings and watches hide bacteria and tear gloves.

Five entries on the two methods of surgical hand antisepsis and on drying.

Two equivalent methods.

TSC 404 Surgical Hand Antisepsis

Surgical hand antisepsis is done with an antimicrobial soap and water scrub or with an alcohol-based rub, before sterile gloves. The international guideline found the two equivalent for preventing infection. The facility chooses products that meet recognized standards. The methods are not combined, because water left on the hands weakens the rub. Between procedures, the rub or scrub is repeated without another handwash, and where water quality is uncertain, the rub is recommended. The method matters less than doing it correctly and completely.

The soap scrub.

TSC 405 The Scrub With Soap

In the soap method, attire is on and jewelry off. The hands and forearms are wet, antimicrobial soap is applied, and every surface is scrubbed for the time the manufacturer recommends. They are rinsed and dried with a sterile towel, touching nothing unsterile, not even the sink or taps. Follow the product's time exactly: shorter leaves bacteria, and longer strains already irritated skin. If the scrub is interrupted or the hands touch something unsterile, it starts again.

The alcohol rub.

TSC 406 The Alcohol Rub Method

In the rub method, a surgical hand rub goes on clean, completely dry hands and forearms. Enough is used to keep them wet throughout, every surface is covered for the manufacturer's time, and they dry completely before gloves go on. Alcohol rubs are flammable and weakened by wet hands, so dry hands first, a full application, and complete drying are all part of the method.

Forearms too.

TSC 407 Hands and Forearms Both

The scrub covers the forearms as well as the hands, because gown cuffs and gloves overlap the lower arm. By either method, every surface is treated for the full time and dried before gowning. Missing the wrists leaves an untreated gap under the cuffs.

Drying correctly.

TSC 408 Drying the Hands

After a soap scrub, hands and arms are dried with a sterile towel, often supplied with the gown pack; after a rub, they air-dry completely. Either way they are dry before the gown is lifted. Wet hands can soak through a gown or glove and carry bacteria with them.

Eight entries on gowning, the two gloving methods, double gloving, and the fixed order that ties them together.

Putting on the gown.

TSC 409 Gowning Yourself

The gown pack was opened onto a clean surface before the scrub, with gloves opened onto its wrapper. Lift the folded gown straight up, step back into open space, and let it unfold without touching anything. Slide the hands into the armholes, and for closed gloving keep them inside the sleeves. An assistant secures the back. A gown that brushes anything unsterile while unfolding is replaced, so the open space behind you is part of the technique.

Hands inside the sleeves.

TSC 410 Hands Stay Inside the Cuffs

For closed gloving, the hands stay inside the gown sleeves and never touch the cuff edges until the gloves are on. Gloves are handled through the sleeve fabric, so bare skin never touches a glove's outside. If a hand slips through early, it becomes open gloving, and facility policy decides how to continue.

Gloving inside the sleeves.

TSC 411 Closed Gloving

Closed gloving is used with a sterile gown. The glove package is turned so the fingers point toward you. Through the sleeve, one hand grasps its glove and flips it onto the palm, fingers toward you, without leaving the cuff. The other sleeved hand pulls the glove's edge over the cuff and hand, and the sleeve is pulled so the glove follows on. The other hand is gloved the same way, and a second pair can go over the first. It feels awkward at first; practise under supervision, and follow your facility's procedure.

Gloving without a gown.

TSC 412 Open Gloving

Open gloving is used when no sterile gown is worn, as in some bedside sterile procedures. The bare hand touches only the inside of the first glove's cuff; the gloved fingers slide under the second glove's cuff to pull it on. Hands stay above the waist, and gloves are checked for tears.

Two pairs.

TSC 413 Double Gloving

Double gloving is advised for scrubbed team members. Pinpoint holes develop from wear, and punctures often happen unnoticed, so a second glove reduces exposure to blood and fluids. It is not a reason to ignore a tear; a damaged glove is still changed.

The right size.

TSC 414 Choosing Glove Size and Material

Sterile gloves come in many sizes and in latex or latex-free materials. A good fit allows comfortable movement without friction or fatigue, and latex-free gloves serve staff or patients with latex allergy. Too large snags and tears; too small tires the hands.

The fixed order.

TSC 415 Preparing to Scrub: The Order of Steps

Scrubbing, gowning and gloving follow a fixed order, so nothing is touched after the hands are prepared. Put on head covering, eye protection and mask. Open the gown pack and gloves onto a clean surface. Perform hand antisepsis by the facility's method. Dry the hands and arms. Put on the gown, hands inside the sleeves, and have an assistant secure the back. Then glove by the closed method, and add a second pair. A mask adjusted after scrubbing, or a glove packet opened with scrubbed hands, means starting again.

Someone else ties the back.

TSC 416 The Assistant Secures the Back

The wearer cannot tie the back of a sterile gown, so an assistant does. The circulating nurse or another unscrubbed person fastens the back, touching only the parts that are not sterile. Gowns close differently, so follow the procedure for your facility's gowns.

Six entries on tears, removal, hands, face and skin, then two worked examples. The opening idea is paid off at the first.

A glove that is torn.

TSC 417 Changing a Contaminated Glove

A torn, punctured or contaminated glove is replaced at once, not at a convenient moment. Spare sterile gloves are kept for this, the change follows facility procedure, and the wearer says aloud that a glove was contaminated. Reporting matters, because a punctured glove can also mean a needlestick.

Holes nobody sees.

TSC 418 Glove Punctures You Cannot See

Glove punctures often happen without the wearer noticing, from wear and from needles and instruments. That is why double gloving is advised and why hands are still prepared beneath. Gloves are a barrier, not a guarantee.

Taking it all off.

TSC 419 Removing Gown and Gloves

At the end of a case, gown and gloves are removed so their contaminated outer surfaces do not touch skin or clothing. The soiled side is turned inward as each comes off, the items are discarded properly, and hand hygiene follows. Most self-contamination happens during removal, so take it slowly.

Hands where you can see them.

TSC 420 Hands Within Sight

Once gowned and gloved, the scrub person keeps the hands above the waist and in sight. Hands below the waist are considered contaminated, so resting hands stay in front of the body at or above waist level. If they drop, facility procedure decides the fix.

Mask and eyes.

TSC 421 Masks and Eye Protection When Scrubbed

The mask covers nose and mouth, protecting the patient from the wearer's breath and the wearer from splashes. Goggles or a face shield protect the eyes, and personal glasses are not adequate. Mask and eye protection are worn together whenever splashes may occur, and both go on before the scrub, because they cannot be adjusted afterwards. Eye protection is removed for comfort more than any other protection, and eye splashes are a common exposure, so choose eyewear that fits and does not fog, and keep it on.

Skin that suffers.

TSC 422 Skin Problems and Scrubbing

Frequent hand preparation can cause irritation, dryness and dermatitis. Irritation is less common with alcohol rubs than with some soap scrubs, though any product stings broken skin. Broken skin is a route for infection, so skin problems are reported to occupational health.

A student's first scrub.

TSC 423 A First Scrub, Step by Step

A worked example, constructed for this course, pays off the opening idea. Ellis, a student, removes a watch and ring, checks the nails, and puts on head covering, eye protection and mask. The gown pack and two pairs of gloves are opened onto a clean surface. At the sink, Ellis scrubs every surface of hands and forearms for the label's time, rinses, and walks in touching nothing. Ellis dries with the sterile towel, lifts the gown, steps back and lets it unfold, hands stopping inside the sleeves, and the circulator secures the back. Ellis closed-gloves, then adds the outer pair. The preceptor notes one slip, a thumb touching the cuff edge; Ellis says so, and they go through the facility's procedure. Speed comes later; the order and honesty come first.

A tear near the end.

TSC 424 A Glove Tear at Closing

A worked example, constructed for this course, follows Kim, scrubbed for a long orthopedic case with bone fragments and wires. Loading a needle holder, Kim sees a tear in the left outer glove. Kim stops and says so, steps back, and checks the inner glove: it looks intact, but there is a faint mark on the finger beneath. Kim tells the circulator there may have been a puncture. Both gloves on that hand are replaced under facility procedure. After the case, Kim reports a possible sharps exposure, and the exposure procedure begins. A glove tear is both a sterility problem and a safety problem for the wearer, and both are handled every time.

Look at what you can now do. You can explain how the surgical scrub differs from handwashing, and prepare with attire on and nails and jewelry dealt with first. You can perform hand antisepsis by soap scrub or alcohol rub for the product's time, covering the forearms, and dry correctly. You can gown yourself in open space, glove by the closed and open methods, double glove, and follow the fixed order of steps. And you can change a torn glove at once, remove gown and gloves safely, keep hands in sight, and protect face, eyes and skin. Unit Eighteen opens the field: prepping and draping.