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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
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. Verify the data with the chart. f. Ensure the patient’s identity is correct by checking the identity band.A. Make sure that an informed consent is made and the patient and its family fully understand the risks and consequences of the procedure. e. Nurses’ Role During Surgery Pre-Operative Phase a. Obtain initial vital signs and other monitoring data essential for the success of the procedure. g. Obtaining the medical or surgical history during endorsements is very important in terms of knowing the patient. c. asking the patient’s of his or her name when he or she is conscious. Alleviate the patient’s anxiety about the procedure as well as coordination with other health team members such as the doctor. clergy or orderlies. . b. Communicate with the patient’s folks in times of emergencies during the procedure as well as after the procedure. d.
The nurse is also responsible in informing the surgeon that the instruments or sponges have been properly taken out from the procedure. This must be done with another nurse to help him or her make a proper counting. c. Assist the surgeon during procedure which may involve handing the surgical instruments properly. Exposing only the body parts involved in the surgery. Protect the patient from falls especially during the induction of anesthesia. b. 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. Upon closure of the operative field. d.Intra-Operative Phase a. the nurse is responsible in counting the number of sponges used. . The counting of sponges and instruments is done before the initial closure and after procedure. Keeping the operative field sterile and free from blood. Properly drape the patient. e.
. c. Teach the patient about caring for the operative site as well as advise the activities that must be done for a faster recovery. b. Others may even warrant blood administration for those who suffered a significant amount of blood loss during the surgery.Post-Operative Phase a. Monitor the patient’s vital signs and watch out for side effects of the an anesthesia such as hypothermia and disorientation. a. Administer medications prescribed after the surgery. Assess the vital signs of each patient for every 15 minutes for the first hour and every 30 minutes thereafter.
For Contaminated Areas: 1. Perform hand hygiene prior to any contact with the patient. Prep the most contaminated area last using separate sponges. Ensure surgical site is marked . the vagina or anus should be used once and then discarded. Retract foreskin if prep involves the penis. Perform surgical scrub and/or paint as applicable for the type of surgery being performed. Peripheral intact skin is prepared before open wounds and body orifices. 3. 5. ulcers. 2.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. Sponges used to prep open wounds. or . 2. . 3. When performing a surgical skin prep for necrotizing fasciitis: .if skin is intact perform as usual. however treat intact skin carefully due to loss of structure under the skin. pull foreskin back once prep is completed to prevent compromise to circulation. intestinal stomas. Expose only the area to be prepared to ensure privacy and warmth of the patient. 4. sinuses.Skin Preparation of Specific Operative Areas GENERAL STEPS FOR ALL TYPES OF SKIN PREPARATIONS: 1. using principle of clean to dirty. 4.
Wash hands and don clean disposable gloves. . Short hair stubble will still be evident after clipping. Razor shaves are not recommended. Discard disposable clipper head into an appropriate sharps container. 2. 3. Clean and disinfect the reusable clipper handle after use following manufacturers’ instructions. Stroke against the direction that the hair is growing using short strokes. 6. 5. Use a single use clipper or a clipper with a reusable handle and disposable head.Hair Removal: 1. 7. Remove any stray clipped hair with tape or other adhesive type product to prevent contamination of the surgical site. 4.
Scrub and Paint Surgical Skin Prep: 1. Tuck drip towels under patient as necessary to prevent pooling of solution: . 6. Perform paint. between the patient and positioning devices.in skin/anatomical creases. 7. Cleanse the skin in a linear and circular motion. 5. Don sterile gloves. or near EKG electrodes 4. Blot cleansed area dry with a sterile towel as follows: . Mix an appropriate amount of antiseptic scrub solution with an appropriate amount of warm sterile water in a basin. This allows for sudsing action of the antiseptic scrub solution.Open a towel fully and place it over the site. . under the patient.Lift carefully without rubbing or dragging the fabric over the cleaned area. and . around a tourniquet. Remove drip towels by grasping the edges in a manner to prevent the towel edges from contaminating the prepped skin. 3. Rinse cleansed area using sterile gauze moistened with sterile water. 2. under an electrosurgical dispersive electrode. 8.
4.long hair may be parted along the incision line and hair secured away from the incision with elastic bands. 3. 2.Head and Neck Prepsarations A. Perform scrub and/or paint.Ensure prep solution penetrates through the hair to the scalp and covers all the hair and scalp in the area to be prepped. Management of hair: . Area to be prepped will vary dependent on incision site. Scalp Prep: 1.short hair may have a thin strip of hair clipped along the incision line. . . or .hair removal may or may not occur.
4. The hairline is considered a contaminated area. 10. Ensure a cap or towel is over the patient’s head to keep hair tucked away. Repeat going from medial to lateral canthus. Do not blot solution off of the skin. Instill a 5% povidone solution into the eye. cheek. 3. cheek. use chlorhexidine. Cover the eye with a 4x4 gauze and massage eye gently especially the fornices. Tuck sterile drip towels under patient as necessary to prevent pooling of solution. clean eyelashes of operative eye with cottontipped applicator dipped in 10% povidone iodine prep solution. 7. Eye Prep: 1. Using just one stroke over eyelashes. 6.B. paint operative eye. Instill NSS into the eye. . For patients allergic to iodine. forehead and nose on correct side. forehead and nose on correct side. Do not scrub lashes. (Note: solution of equal parts of BSS and 10% povidone iodine solution make a 5% solution) 8. using ½ circle motions above and below eye. using ½ circle motions above and below eye. Do not touch cornea. 2. Allow to air dry. however DO NOT touch the mucosa or the cornea. Do not use Chlorhexidine or alcohol solutions. Going from medial to lateral canthus. Don sterile gloves. 11. 5. 9. paint operative eye.
and use waterproof tape if necessary to ensure hair is tucked away. Ensure a cap or towel is over the patient’s hair. Face Prep: 1. Perform paint. . 4. 3. 5.C. Prep the external ear if necessary. Do not remove eyebrows. 2. Begin prep at incision site and extend to the periphery of hairline and neck. The hairline is considered a contaminated area.
The hairline is considered a contaminated area. 5. 6. Place absorbent cotton into the external ear canal. and use waterproof tape if necessary to ensure hair is tucked away. . Cleanse the external ear. Remove the absorbent cotton from the external ear canal. Perform paint. Ear Prep: 1. Ensure a cap or towel is over the patient’s hair. 3. 4.D. face and jaw. Extend the prep to the edge of the hairline. 2.
tops of the shoulders. Ensure a cap or towel is over the patient’s hair and use waterproof tape if necessary to ensure hair is tucked away. . Perform scrub. The area to be prepped includes the neck laterally to the table line and up to the mandible. 3.E. 2. Neck Prep: 1. and chest almost to the nipple line.
Area to be prepped includes the chest. neck and shoulder. Perform scrub.Torso Preparations A. Prep the axilla last. Shoulder Prep: 1. 3. Elevate the patient’s arm prior to proceeding with prep. 2. Be careful not to pull the patient’s shoulder laterally to expose the scapular area to avoid dislocation and further injury to the patient. . scapula and axilla on the affected side. upper arm.
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. Chest/Breast Prep: 1. 7. Perform scrub. 2. prep the breast from the incision area. Skin prep for thoracic surgery requires an extension bilaterally of the boundaries for radical breast surgery. use a separate sponge for the axilla. 4. . Prep both sides of the chest for a bilateral procedure.B. For a breast biopsy. 5. including the upper arm to elbow circumferentially and the axilla of the operative side. 6. Prep the axilla last. 3. If incision is in axilla. to include an area beyond the drape fenestration.
Umbilicus is prepped first using sterile cotton-tipped applicators dipped in antiseptic solution. 3. .C. inguinal hernia repair). Area that may be required to be included is from nipple line to upper 1/3 of thighs. Area to be prepped will vary depending on surgery to be performed (ie appendectomy. Discard applicators after use. Abdominal Prep: 1. 2. Laparoscopic cholecystectomy). table level left to table level right (ie. Perform scrub.
E. 3. Frontal prep depends on accessibility when patient is in lateral position. 2. Back Prep: 1. . Perform scrub.D. back and mid-abdominal wall. Flank: 1. Area to be prepped includes shoulder to iliac crest. Back procedure if patient is prone: area to be prepped includes from neck to sacrum. 2. Back procedure: area to be prepped includes the border of the OR table on both sides. Perform scrub.
Prep anus last. and thighs as follows: .Use fresh sponge to prep inner thigh of second leg starting at labia majora and moving laterally using back and forth strokes. Discard sponge when periphery reached. 6.F. Perform scrub. 5. Ensure towel or impervious drape is removed following completion of the preparation. 4. . Place drip towel or impervious drape under buttocks to prevent prep solution from pooling under the patient’s coccyx. Discard sponge when periphery reached. labia. 2. Do not use Chlorhexidine or alcohol solutions. 3. Next: prep vaginal vault using a separate sponge mounted on a forcep.Prep labia majora using downward strokes. First: prep pelvis.Start prep at the pubis and prep to iliac crest using back and forth strokes. including perineum. . perineum. .Use fresh sponge to prep inner thigh of first leg starting at labia majora and moving laterally using back and forth strokes. Vaginal Prep: 1. .
perineum. Next: Using a separate prep set-up. 2. 4. Abdominal/Perineal Prep: 1. The anus is prepped last being the most contaminated area. 4. 3 . H. Perform scrub. . Prep the anus last – do not penetrate the anus itself. anus and thighs.First: Prep perineal area including pelvis. 2. Perform scrub. labia. prep the abdomen. Perianal Prep: 1. Perineal and abdominal prep shall not be performed simultaneously.G. 3. Begin prep outside anal mucosa and extend outward in all directions. Prep area surrounding anus first.
2. 3. Perform scrub. Place a drip sheet under the operative arm/leg prior to prep.Extremity Skin Preparations Extremities: (General) 1. Ensure drip sheet is removed after completion of surgical skin prep. . Elevate limb for prep. A towel tucked around a tourniquet cuff absorbs excess solution. 4.
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. . 4. Cover the stoma with sterile clear plastic adhesive dressing to prevent fecal material from entering the surgical wound. 2. Place a soaked sponge over the stoma before peripheral tissues are prepped and discard at completion of prep. 3. if not part of the surgical site. Prep gently and last if stoma is part of the surgical incision. Should a surgeon request to pack a stoma. Seal off with a sterile adhesive drape.Special Preparations Stomas: 1.
Prep donor site first. 6. mask and eyewear). denuded or traumatized skin. Position drip towels/drip sheet as appropriate. Do not use irritating solutions on denuded areas. Use drip sheet under the wound. Prep surrounding intact skin. 7. 2. Use a colorless antiseptic on the donor site so that the graft vascularity may be evaluated post op. May need to cover the wound with sterile gauze while prepping surrounding areas. 3. Irrigate wound as necessary with sterile normal saline. Use only normal saline to prep burned. 2. 4. Graft Sites 1. Wear appropriate PPE (gloves.Traumatic Wounds: 1. . 5. Use separate set-ups for recipient and donor sites. 3.
lowered BP. thirst. reduced urine output. . Clinical signs: Rapid weak pulse.POST OPERATIVE COMPLICATIONS A. pallor. . cold clammy skin. Circulatory Hemorrhage – Bleeding internally or externally. Preventive intervention: Early recognition of signs. restlessness. increasing respiratory rate.cause: disruption of sutures. insecure ligation of blood vessels.
SOB. adequate fluid intake.Thrombus – Blood clot attached to wall of vein or artery (most commonly the leg veins). . . Embolus – Clot that has moved from its site of formation to another area of the body. abdomen. Clinical signs: Sudden chest pain. pelvis. leg exercises. . low BP). cyanosis. use of estrogen). signs and prevention: same as thrombus. antiemboli stockings. vein injury resulting from surgery of legs. shock (tachycardia.cause. factors causing increased blood coagulability (eg. Preventive Interventions: Early ambulation.cause: venous stasis.
cause: depressed bladder muscle tone from narcotics & anesthetics. handling of tissues during surgery on adjacent organs (rectum. . bladder distention. suprapubic discomfort. vagina).B. inability to void or frequent voiding of small amounts. Urinary Urinary retention – Accumulation of urine in the bladder and inability of the bladder to empty itself. . Clinical signs: Fluid intake larger than output. restlessness. Preventive Intervention: Monitoring of fluid intake and output. interventions to facilitate voiding.
.cause: immobilization and limited fluid intake. cloudy urine. good perineal hygiene. .Urinary tract infection – Inflammation of the bladder. Preventive Intervention: Adequate fluid intake. early ambulation. Clinical signs: Burning sensation when voiding. early ambulation. urgency. lower abdominal pain.
Preventive Interventions: Adequate fluid intake.C. early ambulation. analgesics (decreased intestinal motility). high-fiber diet.cause: lack of dietary roughage. . Clinical signs: Absence of stool elimination. and discomfort. Gastrointestinal Constipation – Infrequent or no stool passage for abnormal length of time (eg. within 48 hours after solid diet started). abdominal distention. .
retching or gagging. then clear fluids. certain medications. abdominal distention. ingesting fluids or foods before return of peristalsis. anxiety. Clinical signs: Complaints of feeling sick to the stomach. Preventive Intervention: IV fluids until peristalsis returns. .Nausea and Vomiting -cause: pain. full fluids and regular diet when peristalsis returns.
lab analysis of wound swab identifies causative microorganism.cause: poor aseptic technique. tenderness. redness. Clinical signs: Purulent exudates. . elevated body temp. wound odor.. Wound Wound infection – Inflammation and infection of incision or drain site.D. .
a.usually result from external physical forces. A closed wound involves underlying tissues without a break in the skin or a mucous membrane. .can be classified as open or closed. .is a break in the continuity of a tissue of the body.WOUND . either internal or external. b. . An open wound is a break in the skin or in a mucous membrane.
commonly result from falls or the handling of rough objects. Lacerations – jagged. metal edges. but the puncturing object may penetrate deeply into the body and may damage organs and soft tissues and sever internal bleeding.degree of bleeding depends on the depth and extent of a cut 3. Punctures – produced by bullets and pointed objects such as pins. . nails and splinters. . irregular or blunt breaks or tears in the soft tissues. 2. Incisions – cuts in body tissues commonly caused by knives. . .TYPES OF WOUNDS 1.bleeding is limited to oozing of blood from ruptured small veins and capillaries.bleeding is usually minor. . broken glass. . Abrasions – results from scraping (abrading) the skin and thereby damaging it.bleeding may be rapid and extensive 4. or other sharp objects.
7.5.commonly caused by animal bites and accidents involving motor vehicle. . roughly circular area..usually followed by heavy bleeding. 6.can be made by innate destructive processes. . . . heavy machinery. guns and explosives.g.First-degree burns are superficial and red. . Burns . shearing.Third-degree wounds go deeper than the dermis and produce dry.g. Avulsions – involve the forcible separation or tearing of tissue from the victim’s body. . . but most ulcers are caused by external forces such as pressure..often has destruction of tissue in a broad. acid). dead tissue. Ulcers .made by external destructive energy (e.Second-degree wounds include damage to the dermis and produce blisters. .ischemia is then created below the surface where the ulcer is seen. friction and moisture. heat) or by external chemicals (e.
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. 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 .
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 .
2. Self adhesive b.Types Of Dressing 1. Dry gauze dressing . Chief advantage is they facilitate wound assessment without removing the dressing. Air and water occlusive dressing c. b. Wet gauze dressing –retains moisture while it removes drainage from the wound. Less bulky than gauze c. 3. Hydrocolloid dressing a. Transparent dressing a. Does not require tape d. Can be left in place up to one week .Permit air to reach the wound. Non Absorbent 4.
Sterile and clean gloves i. Irrigation pack and solution g.Changing of Dressing 1. Sterile saline or water f. Sterile dressings d. Plastic bag or basin e. Dressings are changed per doctor's orders. Supplies and equipment needed a. Eye shield or face guard h. when the wound requires assessment or care. . and when they become loose or saturated with drainage. Waterproof bed pads c. Tape or Montgomery straps 2. Gather supplies and wash hands b.
odor. and consistency of drainage g. Position the patient and expose the area to be redressed. Gently loosen tape toward the wound while supporting the skin around the wound or untie Montgomery straps. being careful not to tear the wound or dislodge any drains. i. b. Explain procedure to patient a. d. Remove the dressing. f. c. Open all sterile equipment and supplies and place within the sterile field. Use sterile saline to moisten dressing if it is sticking to the wound. Remove gloves and dispose in plastic bag. Put on clean non-sterile exam gloves. to prevent discomfort to the patient and/or to maintain integrity of sutures. h. .3. e. Uncap sterile saline or other solution as ordered. Place waterproof pad under patient and prepare plastic bag as receptacle. Establish a sterile field. Assess amount. Put on sterile gloves. color.
Reposition and cover patient.Applying a Sterile Dressing 1. Wash hands. Enter the date and time of the procedure. 2. Enter a description of the wound's color. and will require the use of "wet to dry" dressings. Close and dispose of plastic bag with used supplies. consistency. 9. 7. 8. 4. b. and amount of drainage. All other dressings will overlap each other and cover entire wound 3. Document wound care and all assessments on the appropriate form a. The outer dressings are applied dry. Remove gloves and place in disposal bag CAUTION: Tape should not form a constricting band around the wound or extremity. Tape the dressing. . 5. 6. Cover all inner dressings with a large out dressing. Example: abdominal evisceration. The inner dressings that touch the wound directly will be dampened with a solution (usually normal saline) before application. odor. CAUTION: Some wounds must be kept moist. Lay inner dressing over wound ensuring the dressing extends past the edge of the wound.
starting at the center of the wound. Do not use the same swab/gauze to clean the entire wound .Cleansing the Wound 1. Discard the gauze.Continue this procedure. working away from the wound until clean. Do not cross back to the center of wound. Discard the gauze. . wipe the wound area with an outward spiral motion. • Third stroke . Linear wound • First stroke . wiping from top to bottom. . working outward until wound is clean. Circular wound • First stroke .cleanse the area directly over the wound by wiping from the top to bottom. wiping from top to bottom. • Second stroke .Continue this procedure alternating sides of the wound.cleanse the skin on other side of wound.cleanse the skin area on one side next to the wound. Discard the gauze. 2.
5. if available.Irrigating the Wound 1. 3. Work from cleanest to most contaminated areas. this step is not necessary. Betadine not generally used in irrigation unless severely contaminated. phisohex. check to ensure patient does not have allergies to it. Use enough force to flush out debris but do not squirt or splash fluid 6. DO NOT force solution into wound pockets. gently pat dry the edges of the wound. If the seal of the bottle has not been broken. non-iodine-based solution may be used (Hibiclens. To prevent contamination and to clean the bottle rim. Pour irrigating solution into basin with the label facing the palm 4. Irrigate all portions of the wound. pour a mall amount of the liquid into waste receptacle. An alternate. . hydrogen peroxide). Using sterile gauze. CAUTION: If Betadine (iodine) is being used. Continue irrigating until solution draining from bottom end of wound is clear. Put on sterile gloves and eye shield or face guard. Fill the syringe with solution from the sterile basin. Hold the tip of the syringe just above top end of wound and force fluid into the wound slowly and continuously. 7. 2.
is a stoma on the outer abdominal wall for drainage of urine. or respiratory tract onto the skin. urinary. or urinary diversion. 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. A person who has an ostomy uses a plastic pouch (appliance) to cover the stoma and collect the stool (effluent) or urine. Different kinds of ostomies are named after their anatomic location. or. large intestine to the abdominal wall) and ureterostomy.OSTOMY An ostomy is an opening for the gastrointestinal. .
4. use the other hand to hold tension on the skin in the opposite direction of the pull. At the same time. 6.Ostomy Appliance Procedure 1. 5. If the pouch is drainable. Save the clamp for re-use (note that some pouches cannot be drained). Empty the existing ostomy pouch into a bedpan. 7. use adhesive remover or rubbing alcohol. With one hand. Wash hands and don clean gloves. 3. places a clean towel across the patient’s abdomen under the existing pouch. . gently remove the old wafer from the skin. open it by removing the clamp and unrolling it at the bottom. Fold down the linen to expose the ostomy site. 2. Position the patient so that no skin folds occur along the line of the stoma. 8. If resistance is encountered and the wafer is difficult to remove. beginning at the top and proceeding in a downward direction. according to facility protocol.
Measure the stoma from side to side (approximating the circumference). . Trace the size of the opening obtained in Step 14 onto the paper on the back of the new wafer. If the pouch is nondrainable. Report excess bleeding to the physician. 11. cuts the opening. dispose of it according to agency protocol. b. 14. c.9. 17. Allow the area to dry. Use a standard stoma measuring guide placed over the stoma. Place the old pouch and wafer in a plastic bag for disposal. 15. Use warm water and mild soap to cleanse stoma and surrounding skin. Re-use a previously cut template. Inspect stoma and peristomal skin. 13. Wafer opening is approximately 1/16 to 1/8 inch (1.5–3 cm) larger than the circumference of the stoma. 16. Measure the size of the stoma in one of the following ways: a. 12. Places a clean 4×4 gauze pad over the stoma. Remove gloves and wash hands. 10.
fold the end of the pouch over the clamp and close the clamp. attaches the bag following manufacturer’s instructions. 19. Center the wafer opening around the stoma and gently press down. Some resources suggest first holding the wafer between the palms of the hands to warm the adhesive ring.18. Peel the paper off the wafer.g. applies skin barrier powder or paste.. a. If using a two-piece system. 22. wipes around stoma with skin-prep. Remove the gauze. 21. 20. b. apply them at this time (e. NOTE: Some ostomy wafers come with an outer ring of tape attached. When the seal is complete. c. place the wafer on first. If so. make sure the bag is pointed toward the patient’s feet. For an open-ended pouch. Don clean procedure gloves. If using a one-piece pouch. If ostomy skin care products are to be used. do not remove the backing on this tape until the wafer is securely positioned (Steps 22–24). applies extra adhesive paste). . listening for a “click” to ensure it is secure.
Remove gloves and wash hands. Ask the patient to place her hand over the newly applied wafer to warm the adhesive ring. 25. . Some sources also suggest taping down the edges of the wafer. 26. Dispose of used ostomy pouch following agency policy for biohazardous waste. 24.23. making it adhere better. Return patient to a comfortable position.
Nursing Responsibilities Assessment. and the condition of periostomal skin from the patient’s record to compare with present findings. Acquire baseline data on the size and kind of stoma. the character of the effluent. • the stoma for swelling. the nurse should assess: • the color of the stoma. color. consistency. presence of blood or pus. Prior to and during the procedure. • the patient’s knowledge and understanding of ostomy care. • the periostomal skin for irritation and redness. . • the feces for amount.
• a skin barrier. wash cloth. • a deodorant for a non-odorproof colostomy bag. and in some cases. towel. or sheet to protect the skin. disc. • measuring guide (stoma guidestrip) to measure the stoma. • cleaning materials. • scissors if the appliance does not have a precut opening. warm water. • adhesive with brush to apply it to the bag if needed.Planning. including tissues. . The nurse should assemble the following equipment: • nonsterile gloves. to protect hands. • gauze pad to cover the stoma. • clamp. mild soap. • a water-proof bag for the soiled appliance to minimize odor. in the form of a spray.
Changing an ostomy appliance is outlined in the following procedure: 1. 5. Remove the appliance. Cleanse the periostomal skin and stoma with warm water and soap. either sitting or lying.) 9. Empty the effluent in the pouch. 4. Communicate acceptance and support of the patient. Rationale: Excessive rubbing may abrade the skin. Dry the area thoroughly by patting with a towel. and expose only the stoma area. (Check agency policy on use of soap since soap may be irritating to the skin. Explain the procedure to the patient and/or family member. 6. Provide privacy. . where the patient can learn to care for his/her ostomy as he/she would at home. Assist the patient to a comfortable position. 7. preferably in the bathroom. 2. 8. peeling the bag off slowly while holding the patient’s skin taut.Intervention. Unfasten the belt and check the method of adhesion. 3.
• condition of stoma and peristomal skin • patient’s response • amount. or liquid such as Skin Prep. The opening of the faceplate should be approximately 1/16” larger than the stoma. 14. wash hands. Prepare and apply the skin barrier which may be in the form of a disc or sheet such as Stomahesive. Rationale: Close fit of the barrier (faceplate) prevents contact of skin with effluent. Check the fit of the appliance. 15. 13. 648 12. and dry. and consistency of drainage . Refer to the manufacturer’s instructions for a specific produce. a spray. Rationale: Any seepage from the stoma will be absorbed in the tissue or gauze pad. Measure the effluent if ordered. or a karaya product. color. Remove and discard gloves. 11. Document in patient’s record. Discard or cleanse the bag. Place a piece of tissue or gauze pad over the stoma. rinse. Measure the size of the guidestrip. Wash soiled belt with warm water and mild soap.10. 16.
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 .
7. 5. if required. 3.CUT-DOWN PROCEDURE a. 9. Sterile gloves. Scissors (vascular and suture). 10. Equipment and Supplies. Suture materials. 8. 1. Splint. 6. Sterile towels. Scalpel handle and blades. Supplies for prepping and dressing the wound area. mask. . Other supplies and equipment as required by physician (and available). Intravenous setup. Equipment and supplies used in a venous cutdown are listed below. 2. 4. Hemostats.
2. Basilic vein below the elbow. Cephalic vein below the elbow. .b. Some suggested sites are listed below. Several sites may be chosen depending on the condition of the patient and the fluid to be infused. Basilic vein above the elbow. 1. 3. 4. Saphenous vein above the ankle. Site.
Apply/inject a local anesthetic so the patient will not feel the incision. . Procedure for the Cutdown. 5. Assemble the equipment and supplies. Explain the procedure to the patient. Using a curved hemostat. 6. Wash your hands. 1. Make a transverse cut and dissect the tissue until the vein is visible (see figure 3.7).c. 4. gently spread the underlying tissue to fully expose the vein. 2. Open incision for venous cutdown. Prepare and stabilize the site. 3. Figure 3-7.
Leave enough vein between the two ties to insert the catheter. . Lift the vein and put two threads of suture under it (see figure 3-8).7. Thread under vein. Tie both threads and pull in opposite directions. Figure 3-8. 8.
(See figure 3-9) Figure 3-9. Nick vein with scalpel.(9) Nick the vein with a scalpel (or cut with vascular scissors). .
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. .
Physician will specify when to remove the skin sutures. Suture incision. Figure 3-11. Apply a sterile dressing and tape the catheter in place. . Suture the incision and apply an antibiotic ointment (see figure 3-11). Outer tape should show catheter size. Attach catheter to previously prepared infusion set and close the wound. 13. 12. and inserter's initials. 15.11. date and time of insertion. The procedure must be documented (usually in Nursing Notes). 14.
4. instruct client to increase daily fluid intake. Provide privacy. 5.Colostomy Care Do’s and Don’ts Do’s 1. the use of drinking straws and chewing gum. encourage oral intake of fluids and bland food. Don’ts 1. and to drink hot liquids and fruit juices especially prune juice. 6. 3. Don't take any medication unless you know it will dissolve quickly and be fully absorbed. . For diarrhea. Avoid eating gas-forming foods. Regular exercise. onions and cauliflower. such as cabbage. When constipated. 6. Client should be encouraged to defecate when the urge is recognized. 3. beans. 4. Don’t eliminate salt from diet. Avoid fasting. Don’t put things into the stoma. Don’t give blood. 2. Limit carbonated beverages. 5. 2.
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