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Informed Consent / Surgical Consent / Operative Permit full knowledge of instructions about operation to be done permission of client its legal purposes: a. Protects client from unwanted procedure b. Protects hospital and surgeon from lawsuit claims B.Verbal Consent when a patient states his consent to a procedure verbally but does not complete a written consent form adequate for procedures or treatments such as a. suture of minor lacerations b. lumbar puncture c. insertion of chest drains d. sedation (e.g. child needing suturing) must be documented in the patient record
C. Written Consent signed by the patient to show that the procedure is the one consented to and that the person understands the nature of procedure. necessary before any medical or surgical treatment such as xray, administration of blood transfusion or other blood products.
Pre-Operative Phase – When the client decided to be operated on and transferred to o.r.
Intra-Operative Phase – When the client is admitted to o.r. and transferred to PACU
Post-Operative Phase – From recovery room /PACU to ward and discharged to follow-up
b. Verify the data with the chart. Obtain initial vital signs and other monitoring data essential for the success of the procedure. Alleviate the patient’s anxiety about the procedure as well as coordination with other health team members such as the doctor. Obtaining the medical or surgical history during endorsements is very important in terms of knowing the patient. Make sure that an informed consent is made and the patient and its family fully understand the risks and consequences of the procedure. Check the orders and special procedures as well as the indication of a surgical procedure. Ensure the patient’s safety by properly checking the side rails and support while transporting in a stretcher. c.A. . clergy or orderlies. Nurses’ Role During Surgery Pre-Operative Phase a. Communicate with the patient’s folks in times of emergencies during the procedure as well as after the procedure. f. g. d. Ensure the patient’s identity is correct by checking the identity band. e. asking the patient’s of his or her name when he or she is conscious.
e. Exposing only the body parts involved in the surgery. Assist the surgeon during procedure which may involve handing the surgical instruments properly. d. b. Protect the patient from falls especially during the induction of anesthesia. the nurse is responsible in counting the number of sponges used. This must be done with another nurse to help him or her make a proper counting. The nurse is also responsible in informing the surgeon that the instruments or sponges have been properly taken out from the procedure. The counting of sponges and instruments is done before the initial closure and after procedure. . Properly drape the patient. He or she must make sure that side rails are up or make sure that the position of the patient is well supported all throughout the procedure.Intra-Operative Phase a. c. Keeping the operative field sterile and free from blood. Upon closure of the operative field.
. Assess the vital signs of each patient for every 15 minutes for the first hour and every 30 minutes thereafter. Monitor the patient’s vital signs and watch out for side effects of the an anesthesia such as hypothermia and disorientation.Post-Operative Phase a. a. c. Others may even warrant blood administration for those who suffered a significant amount of blood loss during the surgery. Administer medications prescribed after the surgery. b. Teach the patient about caring for the operative site as well as advise the activities that must be done for a faster recovery.
intestinal stomas. or . Retract foreskin if prep involves the penis. Prep the most contaminated area last using separate sponges. ulcers. 3. pull foreskin back once prep is completed to prevent compromise to circulation. . 2.Skin Preparation of Specific Operative Areas GENERAL STEPS FOR ALL TYPES OF SKIN PREPARATIONS: 1. Perform hand hygiene prior to any contact with the patient. the vagina or anus should be used once and then discarded. Perform surgical scrub and/or paint as applicable for the type of surgery being performed. however treat intact skin carefully due to loss of structure under the skin. 3. 4. Ensure surgical site is marked .if skin is broken consider the open area to be contaminated and prepare the open area with a separate sponge after preparing the surrounding area. When performing a surgical skin prep for necrotizing fasciitis: . Expose only the area to be prepared to ensure privacy and warmth of the patient.if skin is intact perform as usual. sinuses. Sponges used to prep open wounds. For Contaminated Areas: 1. 4. using principle of clean to dirty. 2. 5. Peripheral intact skin is prepared before open wounds and body orifices.
2. Remove any stray clipped hair with tape or other adhesive type product to prevent contamination of the surgical site. Discard disposable clipper head into an appropriate sharps container. Clean and disinfect the reusable clipper handle after use following manufacturers’ instructions. Wash hands and don clean disposable gloves. 7. Razor shaves are not recommended. Use a single use clipper or a clipper with a reusable handle and disposable head. 6. Stroke against the direction that the hair is growing using short strokes. . Short hair stubble will still be evident after clipping. 4. 3.Hair Removal: 1. 5.
. around a tourniquet. between the patient and positioning devices. This allows for sudsing action of the antiseptic scrub solution. Remove drip towels by grasping the edges in a manner to prevent the towel edges from contaminating the prepped skin. 6. 8. Tuck drip towels under patient as necessary to prevent pooling of solution: . 3.Lift carefully without rubbing or dragging the fabric over the cleaned area. Mix an appropriate amount of antiseptic scrub solution with an appropriate amount of warm sterile water in a basin. 2.Scrub and Paint Surgical Skin Prep: 1. Perform paint.in skin/anatomical creases. Don sterile gloves. under an electrosurgical dispersive electrode. or near EKG electrodes 4. Rinse cleansed area using sterile gauze moistened with sterile water. Cleanse the skin in a linear and circular motion. 7. 5. Blot cleansed area dry with a sterile towel as follows: . under the patient. and .Open a towel fully and place it over the site.
Scalp Prep: 1. .hair removal may or may not occur. Area to be prepped will vary dependent on incision site. Management of hair: .short hair may have a thin strip of hair clipped along the incision line. 2.Ensure prep solution penetrates through the hair to the scalp and covers all the hair and scalp in the area to be prepped.Head and Neck Prepsarations A.long hair may be parted along the incision line and hair secured away from the incision with elastic bands. 3. or . Perform scrub and/or paint. 4. .
cheek.B. using ½ circle motions above and below eye. however DO NOT touch the mucosa or the cornea. 9. 2. paint operative eye. Eye Prep: 1. Allow to air dry. Using just one stroke over eyelashes. Cover the eye with a 4x4 gauze and massage eye gently especially the fornices. 3. Do not use Chlorhexidine or alcohol solutions. The hairline is considered a contaminated area. Don sterile gloves. Ensure a cap or towel is over the patient’s head to keep hair tucked away. cheek. 5. Do not blot solution off of the skin. Going from medial to lateral canthus. Instill NSS into the eye. . clean eyelashes of operative eye with cottontipped applicator dipped in 10% povidone iodine prep solution. 11. 6. Repeat going from medial to lateral canthus. Do not scrub lashes. forehead and nose on correct side. 7. For patients allergic to iodine. 10. Tuck sterile drip towels under patient as necessary to prevent pooling of solution. using ½ circle motions above and below eye. 4. Do not touch cornea. forehead and nose on correct side. (Note: solution of equal parts of BSS and 10% povidone iodine solution make a 5% solution) 8. Instill a 5% povidone solution into the eye. use chlorhexidine. paint operative eye.
3. Face Prep: 1. 5. . Do not remove eyebrows. 4. Ensure a cap or towel is over the patient’s hair. Perform paint. Begin prep at incision site and extend to the periphery of hairline and neck. 2. Prep the external ear if necessary.C. The hairline is considered a contaminated area. and use waterproof tape if necessary to ensure hair is tucked away.
3. and use waterproof tape if necessary to ensure hair is tucked away. face and jaw. Cleanse the external ear. Perform paint. The hairline is considered a contaminated area. 6. Ensure a cap or towel is over the patient’s hair.D. . Ear Prep: 1. Remove the absorbent cotton from the external ear canal. Extend the prep to the edge of the hairline. 5. 2. 4. Place absorbent cotton into the external ear canal.
3. Ensure a cap or towel is over the patient’s hair and use waterproof tape if necessary to ensure hair is tucked away. . The area to be prepped includes the neck laterally to the table line and up to the mandible. Perform scrub. tops of the shoulders. and chest almost to the nipple line. Neck Prep: 1.E. 2.
scapula and axilla on the affected side. Prep the axilla last. Area to be prepped includes the chest. 3. Be careful not to pull the patient’s shoulder laterally to expose the scapular area to avoid dislocation and further injury to the patient.Torso Preparations A. neck and shoulder. 2. . upper arm. Perform scrub. Elevate the patient’s arm prior to proceeding with prep. Shoulder Prep: 1.
Chest/Breast Prep: 1. If incision is in axilla. For a breast biopsy. 3. prep the breast from the incision area. Prep both sides of the chest for a bilateral procedure. Area to be prepped includes from the top of the shoulder to below the diaphragm and from the edge of the non-operative breast to the tablelevel of the operative side. 2.B. 6. 4. to include an area beyond the drape fenestration. 7. . Skin prep for thoracic surgery requires an extension bilaterally of the boundaries for radical breast surgery. Prep the axilla last. Perform scrub. including the upper arm to elbow circumferentially and the axilla of the operative side. use a separate sponge for the axilla. 5.
3. Perform scrub. 2. Area that may be required to be included is from nipple line to upper 1/3 of thighs. Abdominal Prep: 1. Laparoscopic cholecystectomy).C. inguinal hernia repair). . Umbilicus is prepped first using sterile cotton-tipped applicators dipped in antiseptic solution. Discard applicators after use. Area to be prepped will vary depending on surgery to be performed (ie appendectomy. table level left to table level right (ie.
Area to be prepped includes shoulder to iliac crest. Back procedure if patient is prone: area to be prepped includes from neck to sacrum. back and mid-abdominal wall. . Perform scrub. 3. 2. 2. Back Prep: 1. Back procedure: area to be prepped includes the border of the OR table on both sides. Perform scrub.D. E. Frontal prep depends on accessibility when patient is in lateral position. Flank: 1.
4.Use fresh sponge to prep inner thigh of second leg starting at labia majora and moving laterally using back and forth strokes. 5. Discard sponge when periphery reached. Discard sponge when periphery reached. Perform scrub.Use fresh sponge to prep inner thigh of first leg starting at labia majora and moving laterally using back and forth strokes. . 6. Do not use Chlorhexidine or alcohol solutions. including perineum.F. 2. and thighs as follows: . . . .Prep labia majora using downward strokes. perineum. labia. 3. Vaginal Prep: 1. Next: prep vaginal vault using a separate sponge mounted on a forcep. Prep anus last.Start prep at the pubis and prep to iliac crest using back and forth strokes. First: prep pelvis. Place drip towel or impervious drape under buttocks to prevent prep solution from pooling under the patient’s coccyx. Ensure towel or impervious drape is removed following completion of the preparation.
3. prep the abdomen. 2. . 4. Begin prep outside anal mucosa and extend outward in all directions. Perianal Prep: 1. anus and thighs. Perform scrub.First: Prep perineal area including pelvis. 3 . 2. Abdominal/Perineal Prep: 1. 4. Perform scrub.G. Next: Using a separate prep set-up. Prep area surrounding anus first. The anus is prepped last being the most contaminated area. Prep the anus last – do not penetrate the anus itself. H. labia. perineum. Perineal and abdominal prep shall not be performed simultaneously.
Elevate limb for prep. 4. 3. Place a drip sheet under the operative arm/leg prior to prep. Perform scrub. Ensure drip sheet is removed after completion of surgical skin prep. 2.Extremity Skin Preparations Extremities: (General) 1. . A towel tucked around a tourniquet cuff absorbs excess solution.
Upper Extremities: Upper Arm: The area to be prepped includes: entire circumference of the arm to the midforearm, over the shoulder, scapula and axilla (prep last). 1. Begin the prep at the incision, prep to the proximal and distal boundaries. 2. An extremity prep may be done in two stages to provide adequate support to joints and to ensure that all areas are prepped. Hand: The area to be prepped includes: the hand to mid forearm. 1. Hand and fingernails may require pre-cleaning prior to skin prep. 2. Begin prep at the incision site and complete one side of the hand, continue prep on the opposite side of the hand, working in circular motion towards the elbow. 3. During the prep, the nurse wearing sterile gloves may hold the patient’s painted fingers to assist in manipulation of hand during the prep.
Lower Extremities: Hip:
Area to be prepped includes: abdomen on the affected side, thigh to below the knee, the buttocks on the affected side, the groin, and the pubis. 1. Perform scrub. 2. Begin the prep at the incision site. Proceed to periphery which is abdomen midline, inferior rib cage, below knee. Prep the groin and perineum last.
Leg and Foot: 1. Perform scrub. 2. Elevate limb. 3. Area to be prepared may vary depending on surgery to be performed. 4. Prepping the foot should include a scrub prior to paint in order to reduce the bacterial counts between the toes and under toenails. 5. If top of leg prepped, place a drip towel between the groin and the fold of the upper thigh to prevent pooling in the area. Prepping for knee surgery: 1. Foot may be contained within a sterile drape; - with one prep sponge, prep circumferentially starting at incision site and proceed with prep to tourniquet. - with a new sponge, prep circumferentially starting at incision site and prep to ankle.
ensure that a radiopaque Betadine soaked sponge is used. Should a surgeon request to pack a stoma. if not part of the surgical site. Cover the stoma with sterile clear plastic adhesive dressing to prevent fecal material from entering the surgical wound. 4. Seal off with a sterile adhesive drape. Prep gently and last if stoma is part of the surgical incision. 2.Special Preparations Stomas: 1. . 3. Place a soaked sponge over the stoma before peripheral tissues are prepped and discard at completion of prep.
Do not use irritating solutions on denuded areas. Graft Sites 1. 3. Irrigate wound as necessary with sterile normal saline. 6. 5. 4. denuded or traumatized skin. 2. May need to cover the wound with sterile gauze while prepping surrounding areas. 2. 3. Use only normal saline to prep burned. Wear appropriate PPE (gloves. Prep surrounding intact skin. Position drip towels/drip sheet as appropriate.Traumatic Wounds: 1. . mask and eyewear). Use separate set-ups for recipient and donor sites. 7. Use a colorless antiseptic on the donor site so that the graft vascularity may be evaluated post op. Use drip sheet under the wound. Prep donor site first.
Clinical signs: Rapid weak pulse.POST OPERATIVE COMPLICATIONS A. Circulatory Hemorrhage – Bleeding internally or externally. Preventive intervention: Early recognition of signs. thirst. insecure ligation of blood vessels. reduced urine output. restlessness. lowered BP.cause: disruption of sutures. cold clammy skin. . pallor. increasing respiratory rate. .
. shock (tachycardia. use of estrogen). vein injury resulting from surgery of legs. pelvis.cause: venous stasis. SOB. signs and prevention: same as thrombus. . adequate fluid intake. cyanosis. Preventive Interventions: Early ambulation. antiemboli stockings.cause. Embolus – Clot that has moved from its site of formation to another area of the body. . leg exercises. abdomen. factors causing increased blood coagulability (eg.Thrombus – Blood clot attached to wall of vein or artery (most commonly the leg veins). Clinical signs: Sudden chest pain. low BP).
handling of tissues during surgery on adjacent organs (rectum. restlessness. .B. suprapubic discomfort. . Urinary Urinary retention – Accumulation of urine in the bladder and inability of the bladder to empty itself. Clinical signs: Fluid intake larger than output. inability to void or frequent voiding of small amounts. interventions to facilitate voiding.cause: depressed bladder muscle tone from narcotics & anesthetics. Preventive Intervention: Monitoring of fluid intake and output. bladder distention. vagina).
good perineal hygiene.cause: immobilization and limited fluid intake. Preventive Intervention: Adequate fluid intake. urgency. .Urinary tract infection – Inflammation of the bladder. early ambulation. cloudy urine. Clinical signs: Burning sensation when voiding. . early ambulation. lower abdominal pain.
high-fiber diet. Gastrointestinal Constipation – Infrequent or no stool passage for abnormal length of time (eg.cause: lack of dietary roughage. analgesics (decreased intestinal motility). Clinical signs: Absence of stool elimination.C. Preventive Interventions: Adequate fluid intake. . early ambulation. . abdominal distention. within 48 hours after solid diet started). and discomfort.
. Preventive Intervention: IV fluids until peristalsis returns. abdominal distention. certain medications. full fluids and regular diet when peristalsis returns. retching or gagging. then clear fluids. anxiety. Clinical signs: Complaints of feeling sick to the stomach. ingesting fluids or foods before return of peristalsis.Nausea and Vomiting -cause: pain.
. .cause: poor aseptic technique. tenderness. wound odor. Wound Wound infection – Inflammation and infection of incision or drain site. redness. lab analysis of wound swab identifies causative microorganism. Clinical signs: Purulent exudates..D. elevated body temp.
. . .WOUND . b.usually result from external physical forces.can be classified as open or closed. An open wound is a break in the skin or in a mucous membrane. A closed wound involves underlying tissues without a break in the skin or a mucous membrane.is a break in the continuity of a tissue of the body. either internal or external. a.
metal edges. .TYPES OF WOUNDS 1. .commonly result from falls or the handling of rough objects. broken glass. nails and splinters. irregular or blunt breaks or tears in the soft tissues. .bleeding is usually minor.degree of bleeding depends on the depth and extent of a cut 3. Punctures – produced by bullets and pointed objects such as pins. . . but the puncturing object may penetrate deeply into the body and may damage organs and soft tissues and sever internal bleeding.bleeding is limited to oozing of blood from ruptured small veins and capillaries. Abrasions – results from scraping (abrading) the skin and thereby damaging it. or other sharp objects. . Lacerations – jagged.bleeding may be rapid and extensive 4. Incisions – cuts in body tissues commonly caused by knives. 2.
but most ulcers are caused by external forces such as pressure.can be made by innate destructive processes. friction and moisture. heavy machinery.Second-degree wounds include damage to the dermis and produce blisters.5. .First-degree burns are superficial and red.g.usually followed by heavy bleeding. acid). . roughly circular area. heat) or by external chemicals (e.g. shearing. ..often has destruction of tissue in a broad.ischemia is then created below the surface where the ulcer is seen. Ulcers . Avulsions – involve the forcible separation or tearing of tissue from the victim’s body. .commonly caused by animal bites and accidents involving motor vehicle. . dead tissue.Third-degree wounds go deeper than the dermis and produce dry.. 7. guns and explosives. . Burns . . 6.made by external destructive energy (e. .
The cycle can then be repeated Astringent action (coagulate protein) to remove surface debris from the wound • The compress can stick to the wound surface or there may be local pain from application or removal • Faulty technique can introduce infection .METHODS OF WOUND CLEANSING Cleansing method Compress Description Purpose Potential risks Gently pressing excess moisture from a moistened gauze/cloth applied to the wound and removing after wound contact to remove surface debris.
Irrigation Steady flow of solution across wound surface Hydrate the wound Remove deeper debris Assist with visual exam • More trauma if pressure too high • Splash back • High pressure may drive bacteria into deeper compartments Soaking Immersion of wound in solution applying an over-hydrated cloth or gauze to the wound surface (no removal of excess moisture prior to application) Hydrate the wound Allow for physical removal of debris • Disruption of moisture balance • Maceration of surrounding skin • Impaired healing with introduction of bacteria from immersion fluid .
Can be left in place up to one week . 2. Chief advantage is they facilitate wound assessment without removing the dressing. b. 3. Wet gauze dressing –retains moisture while it removes drainage from the wound. Does not require tape d. Transparent dressing a.Types Of Dressing 1.Permit air to reach the wound. Self adhesive b. Dry gauze dressing . Hydrocolloid dressing a. Air and water occlusive dressing c. Non Absorbent 4. Less bulky than gauze c.
Tape or Montgomery straps 2. Supplies and equipment needed a. Sterile and clean gloves i. and when they become loose or saturated with drainage. Eye shield or face guard h. Sterile dressings d. Plastic bag or basin e. when the wound requires assessment or care. Dressings are changed per doctor's orders. . Waterproof bed pads c. Irrigation pack and solution g. Gather supplies and wash hands b.Changing of Dressing 1. Sterile saline or water f.
Place waterproof pad under patient and prepare plastic bag as receptacle.3. color. b. Use sterile saline to moisten dressing if it is sticking to the wound. Establish a sterile field. c. Position the patient and expose the area to be redressed. e. f. Put on sterile gloves. Explain procedure to patient a. Assess amount. . h. Remove the dressing. i. Uncap sterile saline or other solution as ordered. Put on clean non-sterile exam gloves. Gently loosen tape toward the wound while supporting the skin around the wound or untie Montgomery straps. Remove gloves and dispose in plastic bag. odor. and consistency of drainage g. being careful not to tear the wound or dislodge any drains. Open all sterile equipment and supplies and place within the sterile field. to prevent discomfort to the patient and/or to maintain integrity of sutures. d.
6. CAUTION: Some wounds must be kept moist. Enter a description of the wound's color. 5. Enter the date and time of the procedure. Reposition and cover patient. 9.Applying a Sterile Dressing 1. 4. Document wound care and all assessments on the appropriate form a. Wash hands. and will require the use of "wet to dry" dressings. All other dressings will overlap each other and cover entire wound 3. 2. Lay inner dressing over wound ensuring the dressing extends past the edge of the wound. consistency. The inner dressings that touch the wound directly will be dampened with a solution (usually normal saline) before application. 7. Close and dispose of plastic bag with used supplies. Example: abdominal evisceration. 8. Remove gloves and place in disposal bag CAUTION: Tape should not form a constricting band around the wound or extremity. . b. Tape the dressing. The outer dressings are applied dry. and amount of drainage. odor. Cover all inner dressings with a large out dressing.
Continue this procedure. • Second stroke . wipe the wound area with an outward spiral motion. wiping from top to bottom. working away from the wound until clean. . Discard the gauze. . Do not use the same swab/gauze to clean the entire wound . working outward until wound is clean.cleanse the skin area on one side next to the wound.starting at the center of the wound. Do not cross back to the center of wound.Continue this procedure alternating sides of the wound. Circular wound • First stroke .Cleansing the Wound 1.cleanse the skin on other side of wound. Linear wound • First stroke . wiping from top to bottom. • Third stroke .cleanse the area directly over the wound by wiping from the top to bottom. Discard the gauze. Discard the gauze. 2.
CAUTION: If Betadine (iodine) is being used. 7. Work from cleanest to most contaminated areas. check to ensure patient does not have allergies to it. phisohex.Irrigating the Wound 1. To prevent contamination and to clean the bottle rim. Hold the tip of the syringe just above top end of wound and force fluid into the wound slowly and continuously. if available. this step is not necessary. non-iodine-based solution may be used (Hibiclens. Pour irrigating solution into basin with the label facing the palm 4. Put on sterile gloves and eye shield or face guard. Use enough force to flush out debris but do not squirt or splash fluid 6. Continue irrigating until solution draining from bottom end of wound is clear. Betadine not generally used in irrigation unless severely contaminated. Fill the syringe with solution from the sterile basin. . Using sterile gauze. gently pat dry the edges of the wound. 2. 5. If the seal of the bottle has not been broken. 3. Irrigate all portions of the wound. pour a mall amount of the liquid into waste receptacle. DO NOT force solution into wound pockets. hydrogen peroxide). An alternate.
. urinary. or urinary diversion. is a stoma on the outer abdominal wall for drainage of urine. A person who has an ostomy uses a plastic pouch (appliance) to cover the stoma and collect the stool (effluent) or urine. or. large intestine to the abdominal wall) and ureterostomy. Different kinds of ostomies are named after their anatomic location. The most common types of ostomies in intestinal surgery are an "ileostomy" (connecting the ileal part of the small intestine to the abdominal wall) and a "colostomy" (connecting the colon. or respiratory tract onto the skin.OSTOMY An ostomy is an opening for the gastrointestinal.
gently remove the old wafer from the skin. use adhesive remover or rubbing alcohol. 4. 5. Wash hands and don clean gloves. If resistance is encountered and the wafer is difficult to remove. At the same time.Ostomy Appliance Procedure 1. Fold down the linen to expose the ostomy site. Position the patient so that no skin folds occur along the line of the stoma. Save the clamp for re-use (note that some pouches cannot be drained). Empty the existing ostomy pouch into a bedpan. 7. use the other hand to hold tension on the skin in the opposite direction of the pull. With one hand. 2. . beginning at the top and proceeding in a downward direction. If the pouch is drainable. open it by removing the clamp and unrolling it at the bottom. 3. according to facility protocol. places a clean towel across the patient’s abdomen under the existing pouch. 6. 8.
Measure the stoma from side to side (approximating the circumference).9. 14.5–3 cm) larger than the circumference of the stoma. c. Re-use a previously cut template. Report excess bleeding to the physician. Use a standard stoma measuring guide placed over the stoma. Place the old pouch and wafer in a plastic bag for disposal. 12. 15. Trace the size of the opening obtained in Step 14 onto the paper on the back of the new wafer. 16. Inspect stoma and peristomal skin. 17. Remove gloves and wash hands. . 13. Measure the size of the stoma in one of the following ways: a. Allow the area to dry. Use warm water and mild soap to cleanse stoma and surrounding skin. cuts the opening. Places a clean 4×4 gauze pad over the stoma. b. 11. dispose of it according to agency protocol. If the pouch is nondrainable. Wafer opening is approximately 1/16 to 1/8 inch (1. 10.
. 21. place the wafer on first. If ostomy skin care products are to be used. c. a. 22.18.g. do not remove the backing on this tape until the wafer is securely positioned (Steps 22–24). If using a two-piece system. NOTE: Some ostomy wafers come with an outer ring of tape attached. Remove the gauze. applies extra adhesive paste). attaches the bag following manufacturer’s instructions. Peel the paper off the wafer. 19. wipes around stoma with skin-prep. When the seal is complete. Some resources suggest first holding the wafer between the palms of the hands to warm the adhesive ring. Don clean procedure gloves. . applies skin barrier powder or paste. For an open-ended pouch. Center the wafer opening around the stoma and gently press down. b. apply them at this time (e. If so. 20. listening for a “click” to ensure it is secure. fold the end of the pouch over the clamp and close the clamp. make sure the bag is pointed toward the patient’s feet. If using a one-piece pouch.
making it adhere better. . 24. Some sources also suggest taping down the edges of the wafer. 25. Return patient to a comfortable position. Ask the patient to place her hand over the newly applied wafer to warm the adhesive ring. Dispose of used ostomy pouch following agency policy for biohazardous waste. 26.23. Remove gloves and wash hands.
consistency. and the condition of periostomal skin from the patient’s record to compare with present findings. presence of blood or pus. • the stoma for swelling. the character of the effluent. Prior to and during the procedure. • the periostomal skin for irritation and redness. Acquire baseline data on the size and kind of stoma.Nursing Responsibilities Assessment. • the patient’s knowledge and understanding of ostomy care. the nurse should assess: • the color of the stoma. color. . • the feces for amount.
mild soap. • adhesive with brush to apply it to the bag if needed. disc. to protect hands. • measuring guide (stoma guidestrip) to measure the stoma. and in some cases. • a skin barrier. • scissors if the appliance does not have a precut opening. • a deodorant for a non-odorproof colostomy bag. • clamp. The nurse should assemble the following equipment: • nonsterile gloves. wash cloth. in the form of a spray.Planning. • a water-proof bag for the soiled appliance to minimize odor. warm water. • gauze pad to cover the stoma. • cleaning materials. including tissues. or sheet to protect the skin. . towel.
Explain the procedure to the patient and/or family member. Provide privacy. Rationale: Excessive rubbing may abrade the skin. (Check agency policy on use of soap since soap may be irritating to the skin. 6. . Cleanse the periostomal skin and stoma with warm water and soap. and expose only the stoma area. Changing an ostomy appliance is outlined in the following procedure: 1. 5. either sitting or lying. 4.Intervention. 2. Assist the patient to a comfortable position. 3. 7. Communicate acceptance and support of the patient. 8. peeling the bag off slowly while holding the patient’s skin taut. where the patient can learn to care for his/her ostomy as he/she would at home. Remove the appliance.) 9. Empty the effluent in the pouch. Dry the area thoroughly by patting with a towel. Unfasten the belt and check the method of adhesion. preferably in the bathroom.
648 12. 14. Rationale: Any seepage from the stoma will be absorbed in the tissue or gauze pad. Prepare and apply the skin barrier which may be in the form of a disc or sheet such as Stomahesive. Check the fit of the appliance. a spray. 16. Wash soiled belt with warm water and mild soap. Measure the effluent if ordered. • condition of stoma and peristomal skin • patient’s response • amount. 15. or liquid such as Skin Prep. and dry. rinse. wash hands. Refer to the manufacturer’s instructions for a specific produce.10. 11. Remove and discard gloves. or a karaya product. Measure the size of the guidestrip. Discard or cleanse the bag. color. and consistency of drainage . Place a piece of tissue or gauze pad over the stoma. Document in patient’s record. 13. The opening of the faceplate should be approximately 1/16” larger than the stoma. Rationale: Close fit of the barrier (faceplate) prevents contact of skin with effluent.
Evaluation: Expected outcomes of the procedure include: • stoma of a healthy color • normal periostomal skin without signs of redness or irritation • the appliance fits snugly and allows no leakage • patient participation is at the appropriate level .
3. 6. Equipment and Supplies. Scissors (vascular and suture). Other supplies and equipment as required by physician (and available). 9. Supplies for prepping and dressing the wound area. Suture materials. Sterile gloves. 5. 8. Equipment and supplies used in a venous cutdown are listed below. 1. . Splint. 7. 4. if required.CUT-DOWN PROCEDURE a. mask. 10. 2. Hemostats. Intravenous setup. Sterile towels. Scalpel handle and blades.
b. Several sites may be chosen depending on the condition of the patient and the fluid to be infused. Site. 3. 1. Basilic vein above the elbow. 4. Basilic vein below the elbow. Saphenous vein above the ankle. Some suggested sites are listed below. Cephalic vein below the elbow. . 2.
. 6. 5.7). Assemble the equipment and supplies. 2. Procedure for the Cutdown. Wash your hands. gently spread the underlying tissue to fully expose the vein.c. 1. Figure 3-7. 4. Open incision for venous cutdown. Explain the procedure to the patient. Prepare and stabilize the site. Apply/inject a local anesthetic so the patient will not feel the incision. Make a transverse cut and dissect the tissue until the vein is visible (see figure 3. 3. Using a curved hemostat.
. Tie both threads and pull in opposite directions. Figure 3-8. 8. Lift the vein and put two threads of suture under it (see figure 3-8).7. Leave enough vein between the two ties to insert the catheter. Thread under vein.
. Nick vein with scalpel.(9) Nick the vein with a scalpel (or cut with vascular scissors). (See figure 3-9) Figure 3-9.
Insert catheter into vein. Insert the proper size plastic catheter into the exposed vein (to near the catheter hub) and secure (see figure 3-10). Figure 3-10. .10.
14. Apply a sterile dressing and tape the catheter in place. Suture incision. .11. Figure 3-11. 13. Outer tape should show catheter size. 12. Attach catheter to previously prepared infusion set and close the wound. date and time of insertion. Suture the incision and apply an antibiotic ointment (see figure 3-11). Physician will specify when to remove the skin sutures. The procedure must be documented (usually in Nursing Notes). 15. and inserter's initials.
instruct client to increase daily fluid intake. 6. and to drink hot liquids and fruit juices especially prune juice. Regular exercise. such as cabbage. Don’t put things into the stoma. 6. 2. Don’t eliminate salt from diet. For diarrhea. Don’ts 1. 2. When constipated.Colostomy Care Do’s and Don’ts Do’s 1. beans. Avoid eating gas-forming foods. 4. Avoid fasting. onions and cauliflower. Don’t give blood. the use of drinking straws and chewing gum. Limit carbonated beverages. . Provide privacy. encourage oral intake of fluids and bland food. 5. 3. 4. 3. Don't take any medication unless you know it will dissolve quickly and be fully absorbed. Client should be encouraged to defecate when the urge is recognized. 5.
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