Chapter 35

Perioperative Nursing

Procedures Checklist
PREOPERATIVE CARE

Procedure 35-1: Teaching Moving, Leg Exercises, Deep Breathing, and Coughing
Purposes
Performed
Preparation Yes No Mastered Comments
1. Assess:
• Vital signs
• Discomfort
• Temperature and color of feet
and legs
• Breath sounds
• Presence of dyspnea or cough
• Learning needs of the client
• Anxiety level of the client
• Client experience with previous
surgeries and anesthesia
2. Determine:
• The type of surgery
• The time of the surgery
• The name of the surgeon
• The preoperative orders the
agency practices for preoperative
care
3. Assemble equipment and supplies:
• Pillow
• Teaching materials, if appropriate
4. Check that potential distracters to
teaching are not present. Include
the family in the teaching, if
appropriate.
Procedure
1. Explain to the client what you are
going to do, why it is necessary, and
how he can cooperate.
2. Wash hands and observe other
appropriate infection control
procedures.
3. Provide for client privacy.
4. Show the client ways to turn in
bed and to get out of bed.
Instruct a client who will have a right
abdominal incision or a right-sided
chest incision to turn to the left side
of the bed and sit up as follows:

• Flex the knees.

• Splint the wound by holding the
left arm and hand or a small
pillow against the incision.
• Turn to the left while pushing
with the right foot and grasping a
partial side rail on the left side of
the bed with the right hand.
• Come to a sitting position on the
side of the bed by using the right
arm and hand to push down
against the mattress and swinging
the feet over the edge of the bed.
Teach a client with left abdominal or
left-sided chest incision to perform
the same procedure but splint with the
right arm and turn to the right.
For clients with orthopedic surgery,
use special aids, such as a trapeze, to
assist with movement.
5. Teach the client the following
three leg exercises:
Alternate dorsiflexion and plantar
flexion of the feet.
Flex and extend the knees, and press
the backs of the knees into the bed
while dorsiflexing the feet. Instruct
clients who cannot raise their legs to
do isometric exercises that contract
and relax the muscles.
Raise and lower the legs alternately
from the surface of the bed. Flex the
knee of the stable leg, and extend the
knee of the moving leg.
6. Demonstrate deep-breathing
(diaphragmatic) exercises as follows:
Place your hands palms down on the
border of your rib cage, and inhale
slowly and evenly through the nose
until the greatest chest expansion is
achieved
Hold your breath for 2 to 3 seconds.
Then exhale slowly through the
mouth.
Continue exhalation until maximum
chest contraction has been achieved.
 7. Help the client perform
deep-breathing exercises.
Ask the client to assume a sitting
position.
Place the palms of your hands on the
border of the client’s rib cage to
assess respiratory depth.
Ask the client to perform deep
breathing, as described in step 6.
8. Instruct the client to cough
voluntarily after a few deep
inhalations.
Ask the client to inhale deeply, hold
the breath for a few seconds, and then
cough once or twice.
Ensure that the client coughs deeply
and does not just clear the throat.
9. If the incision will be painful when
the client coughs, demonstrate
techniques to splint the abdomen.
Show the client how to support the
incision by placing the palms of the
hands on either side of the incision
site or directly over the incision site,
holding the palm of one hand over the
other.
Show the client how to splint the
abdomen with clasped hands and a
firmly rolled pillow held against the
client’s abdomen.
10. Inform the client about the
expected frequency of these
exercises.
Instruct the client to start the
exercises as soon after surgery as
possible.
Encourage clients with abdominal or
chest surgery to carry out deep
breathing and coughing at least every
2 hours, taking a minimum of five
breaths at each session.
11. Document the teaching and all
assessments.
APPLYING ANTIEMBOLI STOCKINGS

Procedure 35-2: applying Antiemboli Stockings

Performed
Preparation Yes No Mastered Comments
1. Assess both lower extremities for:
• Rates, volumes, and rhythms of
posterior tibial and dorsalis pedis
pulses
• Skin color
• Skin temperature
• Presence of distended veins or
edema
• Skin condition
• Homans’ sign
2. Determine:
• Any potential or present
circulatory problems
• The surgeon’s orders involving
the lower extremities
3. Assemble equipment and supplies:
• Tape measure
• Clean antiemboli stockings of
appropriate size and of the type
ordered
• Talcum powder or cornstarch if
appropriate
4. Take measurements as needed to
obtain the appropriate-size
stockings:
• Measure the length of both legs
from the heel to the gluteal fold
(for thigh-length stockings) or
from the heel to the popliteal
space (for knee-length
stockings).
• Measure the circumference of
each calf and each thigh at the
widest point.
• Compare the measurements to
the size chart to obtain stockings
of correct size. Obtain two sizes
if there is a significant difference.
Procedure
1. Explain to the client what you are
going to do, why it is necessary, and
how she can cooperate.
2. Wash hands and observe other
appropriate infection control
procedures.
3. Provide for client privacy.
4. Select an appropriate time to apply
the stockings.
Apply stockings in the morning, if
possible, before the client arises.
Assist the client who has been
ambulating to lie down and elevate
the legs for 15 to 30 minutes before
applying the stockings.
5. Prepare the client.
Assist the client to a lying position in
bed.
Wash and dry her legs as needed.
Dust the ankles with talcum powder
or cornstarch.
6. Apply the stockings.
Reach inside the stocking from the
top, and, grasping the heel, turn the
upper portion of the stocking inside
out so the foot portion is inside the
stocking leg.
Ask the client to point her toes, then
position the stocking on the client’s
foot. With the heel of the stocking
down, and stretching each side of the
stocking, ease the stocking over the
toes, taking care to place the toe and
heel portions of the stocking
appropriately.
Grasp the loose portion of the
stocking at the ankle and gently pull
the stocking over the leg, turning it
right-side out in the process.
Inspect the client’s leg and stocking,
smoothing any folds or creases.
Ensure that the stocking is not rolled
down or bunched at the top or ankle.
Remove the stockings for 30 minutes
every 8 hours, inspecting the legs and
skin while the stockings are off.
Soiled stockings may be laundered by
hand with warm water and mild soap.
Hang to dry.
7. Document:
• The procedure
• Assessment data
• When the stockings are removed
and reapplied
MANAGING GASTROINTESTINAL SUCTION

Procedure 35-3: Managing Gastrointestinal Suction

Performed
Preparation Yes No Mastered Comments
1. Assess:
• Presence of abdominal distention
on palpation
• Auscultated bowel sounds
• Abdominal discomfort
• Vital signs for baseline data
2. Determine:
• Whether the suction is
continuous or intermittent
• The ordered suction pressure
• Whether there is an order to
irrigate the gastrointestinal tube,
and, if so, the type of solution to
use
3. Assemble equipment and supplies:
Initiating Suction
• Gastrointestinal tube in place in
the client
• Basin
• 50-mL syringe with an adapter
• Stethoscope
• Suction device for either
continuous or intermittent
suction
• Connector and connecting tubing
• Disposable gloves
Maintaining Suction
• Graduated container to measure
gastric drainage
• Basin of water
• Cotton-tipped applicators
• Ointment or lubricant
• Disposable gloves
Irrigation
• Disposable gloves
• Stethoscope
• Disposable irrigating set
• Sterile normal saline
Procedure
1. Explain to the client what you are
going to do, why it is necessary, and
how he can cooperate.
 2. Wash hands and observe other
appropriate infection control
procedures.
3. Provide for client privacy.
Initiating Suction
4. Position the client appropriately.
Assist the client to a semi-Fowler’s
position, if it is not contraindicated.
5. Confirm that the tube is in the
stomach.
Put on clean gloves.
Aspirate stomach contents, and check
the acidity using a pH test strip.
Insert air into the tube with the
syringe, and listen with a stethoscope
over the stomach for a swish of air.
6. Set and check the suction.
Connect the appropriate suction
regulator to the wall suction outlet,
and the collection device to the
regulator. Check the suction level by
occluding the drainage tube and
observing the regulator dial during a
suction cycle.
If using a portable suction machine,
turn on the machine and regulate the
suction.
Test for proper suctioning by holding
the open end of the suction tube to the
ear and listening for a sucking noise,
or by occluding the end of the tube
with a thumb.
7. Establish gastric suction.
Connect the gastrointestinal tube to
the tubing from the suction by using
the connector.
If a Salem sump tube is in place,
connect the larger lumen to the
suction equipment. This double-
lumen tube has a smaller tube running
inside the primary suction tube.
Keep the air vent tube of a Salem
sump tube open and above the level
of the stomach when suction is
applied.
After suction is applied, watch the
tubing for a few minutes until the
gastric contents appear to be running
through the tubing into the receptacle.
If the suction is not working properly,
check that all connections are tight
and that the tubing is not kinked.
Coil and pin the tubing on the bed so
that it does not loop below the suction
bottle.
 8. Assess the drainage.
Observe the amount, color, odor, and
consistency of the drainage.
Test the gastric drainage for pH and
blood (by using Hematest) when
indicated.
Maintaining Suction
9. Assess the client and the suction system regularly.
Assess the client every 30 minutes
until the system is running effectively
and then every 2 hours, or as the
client’s health indicates, to ensure that
the suction is functioning properly.
Inspect the suction system for
patency of the system and tightness of
the connections.
10. Relieve blockages if present.
Put on clean gloves.
Check the suction equipment. To do
this, disconnect the nasogastric tube
from the suction over a collecting
basin (to collect gastric drainage);
then, with the suction on, place the
end of the suction tubing in a basin of
water. If water is drawn into the
drainage bottle, the suction
equipment is functioning properly,
but the nasogastric tube is either
blocked or positioned incorrectly.
Reposition the client, if permitted.
Rotate the nasogastric tube, and
reposition it. This step is
contraindicated for clients with
gastric surgery.
Irrigate the nasogastric tube as
agency protocol states or on the order
of the physician.
11. Prevent reflux into the vent lumen
of a Salem sump tube. To prevent
reflux:
Place the vent tubing higher than the
client’s stomach.
Keep the drainage collection
container below the level of the
client’s stomach, and do not allow it
to become too full.
Keep the drainage lumen free of
particulate matter that may obstruct
the lumen
12. Ensure client comfort.
Clean the client’s nostrils as needed,
using the cotton-tipped applicators
and water. Apply a water-soluble
lubricant or ointment.
Provide mouth care every 2–4 hours
and as needed.
13. Empty the drainage receptacle,
according to agency policy or
physician’s order.
Clamp the nasogastric tube, and turn
off the suction.
Put on clean gloves.
If the receptacle is graduated,
determine the amount of drainage.
Disconnect the receptacle.
If the receptacle is not graduated,
empty the contents into a graduated
container, and measure.
Inspect the drainage carefully for
color, consistency, and presence of
substances.
Discard and replace a full receptacle,
or rinse the receptacle with warm
water, and reattach it to the suction.
Turn on the suction and unclamp the
nasogastric tube.
Observe the system for several
minutes to make sure function is
reestablished.
Go to step 17.
Irrigating a Gastrointestinal Tube
14. Prepare the client and the equipment.
Place the moisture-resistant pad under
the end of the gastrointestinal tube.
Turn off the suction.
Put on clean gloves.
Disconnect the gastrointestinal tube
from the connector.
Determine that the tube is in the
stomach. See step 5 above.
15. Irrigate the tube.
Draw up the ordered volume of
irrigating solution in the syringe.
Attach the syringe to the nasogastric
tube, and slowly inject the solution.
Gently aspirate the solution.
 If you encounter difficulty in
withdrawing the solution, inject 20
mL of air and aspirate again, and/or
reposition the client or the nasogastric
tube. If aspirating difficulty
continues, reattach the tube in
intermittent low suction, and notify
the nurse in charge or physician.
After irrigating a Salem sump tube,
inject 10–20 mL of air into the vent
lumen while applying suction to the
drainage lumen.
16. Reestablish suction.
Reconnect the nasogastric tube to
suction.
If a Salem sump tube is used, inject
the air vent lumen with 10 mL of air
after reconnecting the tube to suction.
Observe the system for several
minutes to make sure it is
functioning.
17. Document all relevant information.
Record the time suction was started.
Also record the pressure established,
the color and consistency of the
drainage, and nursing assessments.
During maintenance, record
assessments, supportive nursing
measures, and data about the suction
system.
When irrigating the tube, record
verification of tube placement; the
time of the irrigation; the amount and
type of irrigating solution used; the
amount, color, and consistency of the
returns; the patency of the system
following the irrigation; and nursing
assessments.
SURGICAL DRESSINGS

Procedure 35-4: Cleaning a Sutured Wound and Applying a Sterile Dressing

Performed
Preparation Yes No Mastered Comments
1. Assess:
• Client allergies to wound
cleaning agents
• The appearance and size of the
wound
• The amount and character of
exudates
• Client complaints of discomfort
• The time of the last pain
medication
• Signs of systemic infection
2. Determine:
• Any specific orders about the
wound or dressing
3. Assemble equipment and supplies:
• Bath blanket (if necessary)
• Moisture-proof bag
• Mask (optional)
• Acetone or another solution (if
necessary to loosen adhesive)
• Disposable gloves
• Sterile gloves
• Sterile dressing set; if none is
available, gather the following
sterile items:
o Drape or towel
o Gauze squares
o Container for the
cleaning solution
o Cleaning solution
o Two pairs of forceps
o Gauze dressings and
surgipads
o Applicators or tongue
blades, to apply
ointments
o Additional supplies
required for the
particular dressing
o Tape, tie tapes, or binder
4. Prepare the client and assemble
the equipment.
Acquire assistance for changing a
dressing on a restless or confused
adult.
Assist the client to a comfortable
position in which the wound can be
readily exposed. Expose only the
wound area.
Make a cuff on the moisture-proof
bag for disposal of the soiled
dressings, and place the bag within
reach. It can be taped to the
bedclothes or bedside table.
Put on a face mask, if required.
Procedure
1. Explain to the client what you are
going to do, why it is necessary, and
how she can cooperate.
2. Wash hands and observe other
appropriate infection control
procedures.
3. Provide for client privacy.
4. Remove binders and tape.
Remove binders, if used, and place
them aside. Untie tie tapes, if used.
If adhesive tape was used, remove it
by holding down the skin and pulling
the tape gently but firmly toward the
wound.
Use a solvent to loosen tape, if
required.
5. Remove and dispose of soiled
dressings appropriately.
Put on clean disposable gloves, and
remove the outer abdominal dressing
or surgipad.
Lift the outer dressing so that the
underside is away from the client’s
face.
Place the soiled dressing in the
moisture-proof bag without touching
the outside of the bag.
Remove the under dressings, taking
care not to dislodge any drains. If the
gauze sticks to the drain, support the
drain with one hand and remove the
gauze with the other.
Assess the location, type, and odor of
wound drainage, and the number of
gauzes saturated or the diameter of
drainage collected on the dressings.
 Discard the soiled dressings in the
bag as before.
Remove gloves, dispose of them in
the moisture-proof bag, and wash
hands.
6. Set up the sterile supplies.
Open the sterile dressing set, using
surgical aseptic technique.
Place the sterile drape beside the
wound.
Open the sterile cleaning solution,
and pour it over the gauze sponges in
the plastic container.
Put on sterile gloves.
7. Clean the wound, if indicated.
Clean the wound, using your gloved
hands or forceps and gauze swabs
moistened with cleaning solution.
If using forceps, keep the forceps tips
lower than the handles at all times.
Use the cleaning methods described,
or one recommended by agency
protocol.
Use a separate swab for each stroke,
and discard each swab after use.
If a drain is present, clean it next,
taking care to avoid reaching across
the cleaned incision. Clean the skin
around the drain site by swabbing in
half or full circles from around the
drain site outward, using separate
swabs for each wipe.
Support and hold the drain erect
while cleaning around it. Clean as
many times as necessary to remove
the drainage.
Dry the surrounding skin with dry
gauze swabs, as required. Do not dry
the incision or wound itself. Moisture
facilitates wound healing.
8. Apply dressings to the drain site
and the incision.
Place a precut 4” x 4” gauze snugly
around the drain, or open a 4 x 4
gauze to 4” x 8”, fold it lengthwise to
2” x 8”, and place the 2” x 8” gauze
around the drain so that the ends
overlap.
Apply the sterile dressings one at a
time over the drain and the incision.
Place the bulk of the dressings over
the drain area and below the drain,
depending on the client’s usual
position.
 Apply the final surgipad, remove
gloves, and dispose of them. Secure
the dressing with tape or ties.
9. Document the procedure and all
nursing assessments.