Effective Day :30-04-2024 End Day: 30-04-2027
Aseptic policy and procedure
Procedure Guidelines
Equipment
-Sterile dressing pack containing gallipots or an indented plastic tray, low -linting swabs
and/or medical foam, gloves, sterile field and disposable bag.
Fluids for cleaning and/or irrigation
Hypo-allergenic tape.
Appropriate dressing materials.
Any other material will be determined by the nature of the dressing: special features of the
dressing should be referred to in the patient’s nursing care plan.
Any extra equipment that may be needed during procedure, e.g. sterile scissors.
Appropriate hand hygiene preparation
Procedure & Rational :
1. Explain and discuss the procedure with the patient.
To ensure the patient fully understands the procedure and gives valid consent.
2. Wash hands with soap and warm water, rinse and dry thoroughly.
-Hands must be cleaned before and after each patient contact and prior to commencing the
preparations for aseptic technique, to prevent cross-infection.
3. The trolley must be cleaned prior to use, but also daily, and if visibly or potentially
contaminated. Wash with detergent and warm water, then disinfect with 70% alcohol (spray
or wipes). Alternatively use approved universal sanitising wipes and allow to air dry.
1|Page
Effective Day :30-04-2024 End Day: 30-04-2027
-To provide a clean working surface.
4. Trolleys used for aseptic procedures should be designated for this purpose only and not
used for any other purpose.
-To reduce the risk of contamination
5. Place all the equipment required for the procedure on the bottom shelf of the clean
dressing trolley. Checking that each item is sterile (i.e. the pack is undamaged, intact and
dry.)
-To maintain the top shelf as a clean working surface.
6. Position the patient comfortably so that the area to be dealt with is accessed easily
without undue exposure.
-To allow airborne organisms to settle before the sterile field (or wound) is exposed.
Maintain the patient’s dignity and comfort
7. If the procedure is a dressing and the wound is infected or producing copious amounts of
exudate, put on a disposable plastic apron.
-To minimise the risk of contamination of clothing.
8. Take the trolley to the bedside or treatment room, disturbing screens as little as possible.
-To reduce the risk of airborne contamination.
9. Use alcohol handrub to decontaminate hands.
-Hands may have become contaminated.
10. Loosen the dressing tape and dressing.
2|Page
Effective Day :30-04-2024 End Day: 30-04-2027
-To make it easier to remove the dressing.
11. Wash hands, rinse and dry thoroughly.
-To reduce the risk of contamination.
12. Open outer cover of the sterile pack and gently slide the contents onto the top shelf of
the trolley.
-Prevent the contamination of contents.
13. Open sterile field using only the corners of the paper.
-Potential contamination is kept to a minimum.
14. Open any other packs tipping their contents gently onto the centre of the sterile field.
-Prepare the equipment and reduce the time the wound is uncovered. This reduces the risk of
infection and a drop in the temperature of the wound - delays wound healing.
15. Clean hands with alcohol hand rub gel.
-Hands may become contaminated when handling packs.
16. Place hand in disposable bag and arrange contents of dressing pack.
-Maintain the sterility of contents.
17. Remove the dressing with hand covered with the disposable bag, invert bag and stick to
the trolley.
-Minimise the risk of contamination, by containing used dressing within the bag.
3|Page
Effective Day :30-04-2024 End Day: 30-04-2027
18. Pour cleaning fluid into gallipots/indented plastic tray taking care not to touch the sides.
-Minimise the risk of contamination.
19. put on sterile gloves, touching the inside of the wrist end only.
-To reduce the risk of infection.
-Gloves provide greater sensitivity than forceps and are less likely to cause trauma to the
patient.
20. Lay down sterile field, provided within the dressing pack.
-To minimise the risk of contamination.
-Carry out procedure
21. Once the dressing is completed and the wound has been recovered, remove gloves and
use alcohol handrub gel to decontaminate the hands.
-To reduce the potential risk of spreading infection.
22. Draw back curtains/screens or help the patient back to the bed. Ensure the patient is
comfortable.
-To maintain the patient’s dignity and comfort.
23. Dispose of clinical waste in orange plastic clinical waste bag.
-To prevent potential environmental contamination.
24. Wash hands with liquid soap and warm water, rinse and dry thoroughly.
-Reduce the risk of spreading infection.
4|Page
Effective Day :30-04-2024 End Day: 30-04-2027
25. Wash dressing trolley with detergent and water, and dry with a disposable paper towel .
Alternatively use approved sanitising wipes and allow to air dry.
-Reduce the potential risk of spreading infection.
Position Name Signature
Prepared by Lina Abushalbak
Approved by AIMS
5|Page
