NURS 3005 - Scrubbing, Gowning and Gloving Study Guide

Scrubbing, Gowning and Gloving General hand hygiene recommendations include:  Using one of the two methods of decontamination before and after patient contact, after removing gloves, anytime there is a chance of con ...

Scrubbing, Gowning and Gloving General hand hygiene recommendations include:  Using one of the two methods of decontamination before and after patient contact, after removing gloves, anytime there is a chance of contact with blood or other body fluids, before and after eating, and after using the restroom.  Avoid contact with surfaces in the patient care setting that could be potentially contaminated.  Keep fingernails short, clean, and healthy. If nail polish is worn, make sure it is not chipped or worn.  Artificial nails should not be worn.  Cuticles, hands, and forearms should be free of open lesions and breaks in skin integrity.  All jewelry, including rings, watches, and bracelets should be removed before performing hand hygiene.  Lotions, if used, should be chosen based on infection control professionals, and compatible with the hand antimicrobial agent and gloves used Hand hygiene for Visibly Soiled Hands Health care workers that have visibly soiled hands should not use alcohol-based hand rubs as hand rubs do not remove soil or debris. If hands are visibly soiled they should be washed immediately with plain or antimicrobial soap and water. Steps in the process of washing soiled hands:  Wet hands with warm water.  Apply soap to the hands according to the manufacturer's written instructions, if given.  Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Pay particular attention to the areas overlooked such as the backs of the hands, fingertips, and thumb and in between the fingers.  Rinse hands with warm water and dry thoroughly with a disposable towel.  Use towel to run off the faucet Surgical Hand Antisepsis The term surgical hand antisepsis refers to the antiseptic surgical scrub or antiseptic hand rub performed before donning sterile attire preoperatively. Although scrubbed members of the surgical team wear sterile gloves, the skin of their hands and forearms should be cleaned preoperatively to significantly reduce the number of microorganisms. The moist environment underneath surgical gloves can promote microorganism growth on the hands of the wearer. Also, both surgical and examination gloves can fail during a procedure. Choice of surgical hand antiseptic scrub agents should be limited to that are US Food and Drug Administration (FDA) compliant, have a documented ability to kill organisms immediately upon application, provide antimicrobial persistence to reduce regrowth of microorganisms, and have a cumulative effect over time. The purpose of surgical hand antisepsis/hand scrubs is to:  remove debris and transient microorganisms from the nails, hands, and forearms;  reduce the resident microbial count to a minimum; and  Inhibit rapid rebound growth of microorganisms. Control of Microorganisms Although the skin can never be rendered sterile, it can be made surgically clean by reducing the number of microorganisms. The surgical hand scrub involves a mechanical and chemical process to control two types of organisms that inhabit the skin. The two types of organisms found on the human body are transient and resident organisms Resident organisms Resident organisms are the flora below the skin surface in hair follicles and sebaceous glands and sweat glands. They are adherent and resistant to removal. During the surgical scrub, the chemical action of the microbicidal or antiseptic agent reduces and neutralizes the resident skin flora. Transient organisms People acquire transient organisms by direct contact. These organisms typically attach loosely to the skin surface. During the surgical hand scrub, the mechanical friction of the scrub brush removes almost all of the transient organisms. Surgical Attire The human body and inanimate surfaces inherent to the surgical environment are major sources of microbial contamination and transmission of microbes; therefore, surgical attire and appropriate personal protective equipment (PPE) are worn to promote worker safety and a high level of cleanliness and hygiene within the perioperative environment. The following are recommendations for personnel that work in the semi restricted and restricted areas of the surgical or invasive procedure setting. • Surgical attire should be made of low-linting material, keep shed skin cells from dispersing, provide comfort, and promote a professional appearance. • Surgical attire fabrics should be tightly woven, stain resistant, and durable. Surgical attire should provide comfort in terms of design, fit, breathability, and the weight of the fabric. Scrub Suit When wearing a two-piece scrub suit, it should be secured at the waist, top tucked into the pants, or fit close to the body to prevent skin cells from being dispersed into the environment. Cover Apparel The use of cover apparel (eg, lab coat, cover gown) may be determined at each individual practice setting based on state regulatory requirements and the culture of the health care organization. Wearing cover apparel over surgical attire outside the perioperative suite may be required for some health care personnel in some health care organizations. Some believe that cover apparel decreases the risk of infection however, the use of cover apparel has been found to have little or no effect on reducing contamination of surgical attire. Warm-up Jacket When in the semirestricted or restricted areas, all non-scrubbed personnel should wear a freshly laundered or single-use long-sleeved warm-up jacket snapped closed with the cuffs down to the wrists. Wearing the warm-up jacket snapped closed prevents the edges of the front of the jacket from contaminating a skin prep area or the sterile surgical field. Long-sleeved attire helps contain skin cells that shed from bare arms. Shoes Shoes worn within the perioperative environment should be clean, have closed toes and backs, low heels, non-skid soles and must meet Occupational Safety & Health Administration (OSHA) and the health care organization's safety requirements.  Soiled shoes have been found to contribute to environmental contamination within the perioperative environment. Shoes that are worn only in the perioperative area may help to significantly reduce contamination in the perioperative environment.  Shoes that enclose the foot, have low heels and non-skid soles reduce the risk of injury from slips and falls and from dropped items.  Shoes made of cloth, that are open-toed, or have holes in the top or sides do not offer protection against spilled liquids or sharp items that may be dropped or kicked. Note: According to OSHA (1910.1030) shoe covers are required for cases such as orthopedics and autopsies. In addition, AORN recommends shoe covers for C-sections and trauma cases. Stethoscopes Stethoscopes should be clean and not worn around the neck. Contaminated stethoscopes, tubing and diaphragms may transmit pathogens such as MRSA by indirect contact (e.g., by wearing the stethoscope around the neck and contaminating the skin and surgical attire). Although stethoscopes are not considered part of the surgical attire, health care providers often wear them around their necks as though they were part of surgical attire. Fabric stethoscope tubing covers should not be used. Adding fabric covers to stethoscope tubing may result in the covers acting as fomites (A fomite is an inanimate object or substance, such as clothing, furniture, or soap that is capable of transmitting infectious organisms from one individual to another). ID Badges Identification badges should be secured on the surgical attire top, be visible, and be cleaned if they become soiled. Badge holders such as lanyards, chains, or beads pose a risk for contamination and may be very difficult to clean. Fanny Packs, Backpacks and Briefcases These items should NOT be taken into the semi restricted or restricted areas of the perioperative suite. These items may be constructed of porous materials, may be difficult to clean or disinfect adequately and may harbor pathogens, dust, and bacteria. Head Covers Head coverings should cover all hair on the head including, facial hair, sideburns and neckline. Uncovered hair acts as a filter and collects bacteria. Complete coverage of hair is necessary. It has been shown that shedding from hair can affect surgical wound infection rates. A clean, low-lint surgical head cover or hood that confines hair and covers scalp skin should be worn. This head covering should be designed to minimize microbial dispersal. A single-use head covering should be removed and discarded in a designated receptacle daily or when contaminated. Reusable head coverings should be laundered in a health care-accredited laundry facility after each daily use. Skull caps fail to contain the side hair above and in front of the ears and hair at the nape of the neck. Laundering Surgical attire should be laundered in a health care-accredited laundry facility. Health care-accredited laundry facilities are preferred because they follow industry standards. The Healthcare Laundry Accreditation Council (HLAC) offers voluntary accreditation for those laundry facilities that process reusable health care textiles and which incorporates OSHA and the Centers for Disease Control and Prevention (CDC) guidelines and professional association recommended practices. In contrast, home laundering is not monitored for quality, consistency, or safety. Exposure of health care personnel and their family members to blood and other potentially infectious materials may result from improper handling and decontamination of surgical attire. Home laundering had been shown to be less effective for cleaning surgical attire than attire laundered by health care facilities or commercial laundries. Home laundering may not meet the specified measures necessary to achieve a reduction in antimicrobial levels in soiled surgical attire. Results of a research study showed that the bioburden on home-laundered surgical attire was significantly greater than surgical attire that was facility-laundered; laundered by a third party; or was single-use, disposable attire. Home-laundered clean scrubs at the beginning of the day had the same amount of organisms as worn scrubs at the end of the work day. The Surgical Mask All individuals entering the restricted areas should wear a mask when open sterile supplies and equipment are present. A surgical mask protects both the surgical team and the patient from transfer of microorganisms. A single surgical mask is worn to protect the health care provider from contact with infectious material from the patient (e.g. respiratory secretions, sprays of blood or body fluids) and to protect the patient from exposure to infectious agents carried in the providers' mouth or nose. A study involving 8,500 surgical procedures showed that 26% of exposures to blood were to the heads and necks of scrubbed personnel and that 17% of blood exposures were to circulating personnel outside the sterile field. A mask should cover the mouth and nose and be secured in a manner to prevent venting. A mask that is securely tied at the back of the head and behind the neck decreases the risk of health care personnel transmitting nasopharyngeal and respiratory microorganisms to patients or the sterile field. Infectious particles can reach the wearer's nose and mouth by passing through leaks at the mask-face seal. A fresh clean mask should be worn for every procedure. The mask should be replaced and discarded whenever it becomes wet or soiled. Masks SHOULD NOT be worn hanging down from the neck. The filter portion of a surgical mask harbors bacteria collected from the nasopharyngeal airway. The contaminated mask may cross-contaminate the surgical attire top. Masks should be removed carefully by handling only mask ties. Hand hygiene should be performed after removal of masks. Removing the mask by the ties prevents possible contamination of the hands. Only one mask should be worn at a time. Masks are intended to contain and filter droplets of microorganisms expelled from the mouth and nasopharynx during talking, sneezing, and coughing. Use of a double mask creates an impediment to breathing and does not increase filtration; therefore, this is not recommended. Preparations for a Surgical Hand The surgical hand scrub should be performed before donning the sterile gown and gloves. Effective surgical hand scrubs reduce the number of microorganisms on the nails, hands and arms. If a glove is perforated during surgery, then fewer microorganisms are released into the wound. Some preparation is required before starting the scrub procedure  Before beginning the surgical hand scrub, the gown package containing a sterile gown and towel should be opened and placed on a table or a mayo stand in the operating room.  The gown in the sterile package is folded in such a way that the scrub person can put it on without touching the outer (sterile) side with bare hands.  The table used should not be the main instrument table. Standardized surgical scrub procedures are established within each practice setting to achieve a single standard of care. The degree of microbial reduction achieved by the surgical scrub necessary for prophylaxis of surgical site infections is unknown. Some preparation is required before starting the scrub procedure. Traditional Hand Scrub Procedure Surgical hand antisepsis/hand scrub using a FDA-compliant, traditional antimicrobial scrub agent should include a standardized hand procedure that follows the manufacturer's written directions for use and is approved by the health care facility. A traditional, standardized, surgical hand antisepsis scrub procedure should include, but may not be limited to, the following: 1. Wash hands and forearms with soap and running water immediately before beginning the surgical scrub. 2. Clean the subungual areas of both hands under running water using a disposable nail cleaner. 3. Rinse hands and forearms under running water. 4. Dispense the approved antimicrobial scrub agent according to the manufacturer's written directions. 5. Apply the antimicrobial agent to wet hands and forearms. Some manufacturers may recommend using a soft, nonabrasive sponge. 6. Visualize each finger, hand, and arm as having four sides. Wash all four sides effectively. Repeat this process for opposite fingers, hand, and arm. 7. Repeat this process if directed to do so by the manufacturer's written directions for use. 8. Avoid splashing surgical attire. 9. For water conservation, turn water off when it is not directly in use, if possible. 10. Hold hands higher than elbows and away from surgical attire. 11. Discard sponges, if used, in appropriate containers. 12. In the OR, dry hands and arms with a sterile towel before donning a sterile surgical gown and gloves. Opening the Brush Pack The first steps in the scrubbing procedure are:  Open the sterile scrub brush package, and position it for easy access.  Adjust the water to a comfortable temperature and flow to prevent spraying of the scrub attire.  Wet hands and forearms. Preventing the spraying of water on the scrub attire is essential as water on the nonsterile scrub attire may soak through and contaminate the sterile gown! The steps for lathering and cleaning of fingers  Lather the hands and forearms to two inches above the elbow, using an antimicrobial soap. This loosens surface debris and removes gross contamination.  Rinse hands and arms while keeping the fingers pointed upward so that water drips off at the elbows and away from the scrub attire.  Remove the nail cleaner from the package, clean under the fingernails of both hands with the nail cleaner while holding the hands under running water, and then discard the nail cleaner.  Remove the scrub brush and squeeze it under the water to dispense the soap if the brush contains soap, or apply soap from the soap dispenser.  Hold the brush perpendicular to the fingertips and scrub the nails.  Scrub the fingers using a back and forth motion on all four sides of each finger, including the web spaces of one hand. The scrubbing of palms and arms is the next step after the fingers are scrubbed. The following procedure will explain how this is done.  Scrub the palm and back of the same hand to the wrist using a circular motion.  Maintain lather and ensure that all skin surfaces are sufficiently exposed to the friction of scrubbing and the antimicrobial agent.  Continue at the wrist, scrubbing with a circular motion to two inches above the elbow on all sides of the arm while rotating the arm from back to front.  Transfer the scrub brush to the other hand and repeat all the steps for scrubbing from the fingertips to two inches above the elbow. During scrubbing, turn off the water when not needed The last step of the scrubbing procedure is rinsing.  Rinse hands and arms under running water, starting at the fingertips and working toward the elbows, keeping hands upright and elbows in a downward position. Be careful not to touch faucets or edge of sink when rinsing Protocol for the Alcohol Based Hand Rub If hands are not visibly soiled, an alcohol-based hand rub may be used for routine decontamination of hands after a routine washing with soap and warm water. Degerming with an alcohol-based hand rub is more effective than washing with soap and water and requires much shorter exposure time. Be sure to follow the manufacturer's written directions for product application. To improve adherence to general hand-hygiene recommendations among health care environments, an appropriate alcohol-based agent should be available in convenient locations. Because of the fire hazard inherent in alcohol-based products, health care facilities should consult their local, state, and federal regulations for placement of these alcohol-based hand rub products. A standardized protocol for alcohol-based surgical hand rubs should follow manufacturer's written instructions and include, but may be not be limited to, the following:  Wash hands and forearms with soap and running water immediately before beginning the surgical hand antisepsis procedure.  Clean the subungual areas of both hands under running water using a nail cleaner.  Rinse hands and forearms under running water.  Dry hands and forearms thoroughly with a paper towel.  Dispense the manufacturer-recommended amount of the surgical hand rub product.  Apply the product to the hands and forearms, following the manufacturer's written directions.  Some manufacturers may require the use of water as part of the process.  Rub thoroughly until dry.  Repeat the product application process if indicated in the manufacturer's written directions.  In the OR, don a sterile surgical gown and gloves. Drying Hands and Arms The hands and arms must be thoroughly dried, before donning the gown, to prevent organisms on the wet skin from soaking through and contaminating the sterile gown. This soaking through, known as strike through, allows microorganisms from the wet skin and/or scrub attire to contaminate the sterile gown. Drying of hands and arms includes the following steps:  Grasp the sterile towel near the opened corner and lift it up taking care not to drip water on the gown.  Step away from the table.  Keep the towel away from the nonsterile scrub attire by bending forward slightly keeping hands and elbows up and away from waist.  Let the opened towel unfold to its full length.  Use one half of the towel for one hand and arm, drying the hand first.  With a rotating motion, pat the skin up to two inches above the elbow.  With the dried hand, carefully reverse the ends of the towel and dry the other hand and arm with the unused half.  Make sure that both hands are thoroughly dry.  Discard the towel without dropping hands. Gowning Procedure The following procedure should be followed to don the gown: • The towel, gown, and gloves should be donned from a sterile area away from the main instrument table. • Lift the folded gown directly upward from the sterile package taking care not to contaminate the gown with the edge of the wrapper. • Step back from the table into an unobstructed area. • Carefully locate the neckband and hold the inside front of the gown just below the neckband with both hands. • Let the gown unfold while keeping the inside of the gown toward the body without touching the sterile exterior of the gown with bare hands. • Hold the hands at shoulder level and slip both arms into the armholes simultaneously. Since, at times, when donning the gown it might not unfold completely, it may be necessary for the circulating nurse to assist by pulling the unfolded bottom inside of the gown. Circular Nurse The circulator may assist the scrub person, during gowning, in the following way. • Reach inside the gown and pull the inside seam to bring the gown over the scrub person’s shoulders. • Touch only the ties, Velcro, or snaps, securing the back of the gown at the neck and the waist. • Adjust the gown by grasping the bottom edge and pulling down to eliminate any blousing. • Assist with securing wraparound gown by holding the tie tag from the scrub person as they turn. After the circulator ties the gown, the gown is secured, in the following way. • Hand the long tag tie from the wraparound gown to the circulator or another scrubbed team member, and turn around. • Grasp the tie 4-6” from the tag and pull. • Tie the two together on the side of the gown. If a tag is unavailable, a sterile glove wrapper or a hemostat may be used to assist the scrub person in securing the gown. Assisted Gowning A scrubbed person may assist another member in gowning in the following way. • Open the towel that the other member will use to dry their hands. • Lay the top half of the towel on the team member’s hands without touching their hands. • Hold the gown at the neckband and carefully unfold it. • Keep the hands on the outside of the gown, forming a protective cuff of the neck and shoulder area as the person being gowned holds both arms outstretched. • This will offer the inside of the gown to the other member so they can slip their arms into the sleeves. • Release the gown when the team member’s hands are in the sleeves. Circulator Assistance The circulator reaches inside the gown and pulls the inside seams to bring the gown over the team member’s shoulders to assist in pulling the hands through the cuffs as needed, touching only the ties, snaps, or Velcro, secures the back of the gown at the neck and the waist. The circulator also may adjust the gown by grasping the bottom edge and pulling down to eliminate any blousing such that the scrub person adjusts the sleeves so the cuffs fit properly. Gloving Procedure There are two methods or techniques used to glove the hands of the scrub person. These are: Closed glove technique The scrub person’s hands remain inside the gown sleeves and should not touch the cuff edges. The closed glove method is used for the initial donning of sterile gown and gloves.  Keep both hands within the cuff so that the hands do not touch the cuff edges.  Grasp the folded cuff of the left glove.  Hold the top edge of the cuff in the left hand above the palm.  Place the palm of the glove against the palm of the left hand - the glove fingers point up the forearm.  Grasp the back of the glove cuff in the right hand and turn it over the open end of the left sleeve and hand while holding the top of the left glove and underlying gown sleeve with the covered right hand.  Pull the glove over the extended left fingers onto the wrist by pushing the hand through the glove until it completely covers the cuff of the gown.  Glove the right hand in the same manner.  Inspect the gloves for integrity after donning. This method is not to be used when the scrub person is changing his/her gloves! Open glove technique Closed glove technique The open glove method is used for subsequent gloving. The scrub person’s hands slide all the way through the sleeves and out beyond the cuffs. The closed glove technique should not be used when changing one or both gloves, because once the hand has passed through the cuffs, it is contaminated. The open glove technique is used when a glove must be changed without assistance during a surgical procedure. This technique is also used when performing sterile procedures such as bladder catheterization or insertion of an IV cutdown, when a gown is not worn. To change one glove during the procedure, using the open gloving technique, do the following:  Step away from the sterile field.  Extend the contaminated hand and glove away from the sterile field so that the circulator, using exam gloves to protect their hands, can remove it.  Lift the new sterile glove under the cuff with the uncontaminated gloved hand.  Insert the hand into the glove and pull it on, leaving the cuff turned well down over the hand and avoiding inward rolling of the cuff. (The bare hand does not touch the outside of the glove.)  Rotate the arm and pull the cuff of the glove up and over the sleeve cuff, letting the gloved fingers touch only the outside of the other glove. To change both gloves during the gloving procedure, using the open glove technique, do the following:  Step away from the sterile field.  Extend both contaminated hands and gloves away from the sterile field so that the circulator, using exam gloves to protect their hands, can remove it.  Pick up the left glove cuff with the right thumb and index finger, touching only the edge of the cuff making sure not to contaminate the wrapper with the cuff of the gown.  Pull the glove onto the left hand and leave the glove cuff turned down.  Pick up the right glove with the gloved left hand, keeping the gloved fingers under the folded cuff.  Slide the right hand fingers inside the right glove cuff and pull the glove onto the right hand while avoiding inward rolling of the cuff.  Pull the right glove cuff over the sleeve cuff by rotating the arm.  Place the gloved right hand fingers under the folded left glove cuff, rotate the arm, and pull the left glove cuff over the sleeve cuff.  The gown should be completely fastened before donning gloves to prevent contamination from the gown flaps. Assisted Gloving While gloving another team member, the other person’s right hand should always be gloved first. This process may be reversed for a left handed person.  Pick up the glove with the fingers under the cuff.  Hold the palm of the glove toward the person being gloved.  Stretch the cuff to open the glove and hold your thumbs out to keep them from touching the other team member’s bare hands.  Exert upward firm pressure as the other person inserts their hand into the glove, making sure the hand does not go below the waist.  Unfold the glove cuff over the cuff of the sleeve.  Glove the left hand with the assistance of the team member by repeating the steps.  Hold the tie tag as the other team member turns to secure the wraparound sterile gown when it is used. Assisted Regloving When a team member other than the scrub nurse contaminates a glove during the surgical procedure, the circulator, using exam gloves to protect their hands, will grasp the outside of the glove and pull it off inside out. The team member should then be regloved by the scrub nurse as learned earlier. The options for the scrub nurse who needs to change gloves are to:  Remove both gown and gloves  Have another team member assist in regloving  Use the open glove technique  The closed glove technique should not be used when changing one or both gloves, because once the hand has passed through the cuffs, it is contaminated. Double Gloving Health care practitioners should double-glove during invasive procedures. This means wearing two pairs of gloves, one over the other. A systematic review of 18 clinical trials of gloving practices clearly demonstrates that double-gloving minimizes the risk of exposure of health care workers to blood during invasive procedures.  Wearing two pairs of gloves (double-gloving) significantly reduces the number of perforations to the innermost glove, when compared to the outer glove or single gloves.  Wearing two pairs of gloves does not increase the likelihood of increased perforations to the outermost glove.  Wearing one pair of standard thickness gloves on top of a pair of standard thickness colored gloves facilitates the wearer’s rapid recognition of perforations to the outer glove.  Wearing two layers of colored gloves does not assist in recognizing breaches to the glove closest to the wearer's skin. The Centers for Disease Control and Prevention (CDC), the American College of Surgeons, and the American Academy of Orthopedic Surgeons, support double-gloving during invasive procedures. Maintaining a Sterile Field The surgical team should observe certain precautions to avoid contamination and maintain the sterility of the field. The hands should be kept above the waist and in sight at all times. The back of a wrap around gown is not sterile! The following guidelines are recommended for maintaining a sterile field:  If any part of the sterile attire becomes contaminated, immediate corrective steps must be taken. For example: If a glove becomes contaminated or perforated during surgery, it must be changed immediately.  Once the original gloves are donned, the gown cuffs should be considered contaminated because the scrubbed hand passed through them.  The hands should be kept above the waist and in sight at all times.  The sterile areas in the surgical attire are: o The front of the gown from the table level or sterile field to 2 inches below the neck. o The sleeves from 2 inches above the elbow to the cuff. o The surgical gloves. Removing the Gown At the end of the procedure, the gown is always removed before the gloves to prevent cross-contamination of the wearer’s scrub attire. 1. The circulator unfastens the neck and back closures of the gown. 2. The scrub person should then: Grasp the shoulders of the gown or cross arms and pull it downward from theshoulder and off the arms Turn the sleeves inside out Fold the contaminated surface of the gown to the inside and roll it up Discard the rolled gown in the appropriate receptacle - laundry hamper or trash Removing the Gloves Removing the gloves after removing the gown prevents the bare hands from contamination that would occur from handling the soiled gown. As the gown comes off it usually turns the cuffs of the gloves down. To remove the gloves, the wearer can use the glove-to-glove and then the skin-to-skin technique. This approach protects the hands from the contaminated glove. The following procedure should be followed to remove gloves:  Grasp under the cuff of the left glove with gloved fingers of the right hand and pull it off inside out taking care not to contaminate skin with dirty gloves.  Slip the ungloved fingers of the left hand inside the right glove and slip it off inside out in order to prevent touching of outer portion of the soiled glove, hook the bare finger on the inner side of the glove and pull the glove off.  Discard the gloves in the appropriate receptacle.  Wash hands and arms with soap and water. Module Summary Scrubbing, Gowning and Gloving  The two different scrubbing techniques: o Anatomic timed scrub o Counted stroke scrub  The 5-minute scrub times and the minimum number of strokes required for scrubbing.  Procedure for drying of hands and arms before donning the surgical gown.  The gowning procedure.  The need and importance of a circulator nurse during gowning.  How a scrub person can assist another member in donning a gown.  The gloving procedure.  The two techniques of gloving: o Closed glove technique o Open glove technique  How a scrub person can assist another member in gloving.  How a circulator assists in regloving a scrub member when the gloves are contaminated in a surgical procedure.  The sterile areas of gown and gloves.  Removing of gowns and gloves and the procedure to be followed.