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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
c. g. Communicate with the patient’s folks in times of emergencies during the procedure as well as after the procedure. d. Check the orders and special procedures as well as the indication of a surgical procedure. . Nurses’ Role During Surgery Pre-Operative Phase a. 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. Verify the data with the chart. clergy or orderlies. Obtain initial vital signs and other monitoring data essential for the success of the procedure. Ensure the patient’s safety by properly checking the side rails and support while transporting in a stretcher. Alleviate the patient’s anxiety about the procedure as well as coordination with other health team members such as the doctor. asking the patient’s of his or her name when he or she is conscious.A. e. f. Ensure the patient’s identity is correct by checking the identity band. b.
Upon closure of the operative field. 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. . Keeping the operative field sterile and free from blood.Intra-Operative Phase a. the nurse is responsible in counting the number of sponges used. e. b. This must be done with another nurse to help him or her make a proper counting. Protect the patient from falls especially during the induction of anesthesia. Exposing only the body parts involved in the surgery. The counting of sponges and instruments is done before the initial closure and after procedure. c. Assist the surgeon during procedure which may involve handing the surgical instruments properly. d. The nurse is also responsible in informing the surgeon that the instruments or sponges have been properly taken out from the procedure.
c. Monitor the patient’s vital signs and watch out for side effects of the an anesthesia such as hypothermia and disorientation. b. Others may even warrant blood administration for those who suffered a significant amount of blood loss during the surgery. Teach the patient about caring for the operative site as well as advise the activities that must be done for a faster recovery.Post-Operative Phase a. a. . Assess the vital signs of each patient for every 15 minutes for the first hour and every 30 minutes thereafter. Administer medications prescribed after the surgery.
When performing a surgical skin prep for necrotizing fasciitis: . Prep the most contaminated area last using separate sponges. Retract foreskin if prep involves the penis. Perform hand hygiene prior to any contact with the patient.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. or . 4. 4. using principle of clean to dirty. pull foreskin back once prep is completed to prevent compromise to circulation. 3. ulcers. 3. sinuses. the vagina or anus should be used once and then discarded.Skin Preparation of Specific Operative Areas GENERAL STEPS FOR ALL TYPES OF SKIN PREPARATIONS: 1. . Perform surgical scrub and/or paint as applicable for the type of surgery being performed.if skin is intact perform as usual. 2. Peripheral intact skin is prepared before open wounds and body orifices. however treat intact skin carefully due to loss of structure under the skin. 5. Ensure surgical site is marked . Sponges used to prep open wounds. intestinal stomas. Expose only the area to be prepared to ensure privacy and warmth of the patient. 2. For Contaminated Areas: 1.
Stroke against the direction that the hair is growing using short strokes. 7. . Wash hands and don clean disposable gloves. Razor shaves are not recommended. Use a single use clipper or a clipper with a reusable handle and disposable head. 6. 3.Hair Removal: 1. 5. 4. Clean and disinfect the reusable clipper handle after use following manufacturers’ instructions. Short hair stubble will still be evident after clipping. 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. 2.
in skin/anatomical creases. This allows for sudsing action of the antiseptic scrub solution. 2. and . between the patient and positioning devices. Tuck drip towels under patient as necessary to prevent pooling of solution: . 6. 8. Don sterile gloves. Remove drip towels by grasping the edges in a manner to prevent the towel edges from contaminating the prepped skin. under an electrosurgical dispersive electrode.Lift carefully without rubbing or dragging the fabric over the cleaned area. under the patient. 5. 3. . Rinse cleansed area using sterile gauze moistened with sterile water. Blot cleansed area dry with a sterile towel as follows: . Cleanse the skin in a linear and circular motion. around a tourniquet. Mix an appropriate amount of antiseptic scrub solution with an appropriate amount of warm sterile water in a basin. or near EKG electrodes 4. Perform paint.Scrub and Paint Surgical Skin Prep: 1.Open a towel fully and place it over the site. 7.
long hair may be parted along the incision line and hair secured away from the incision with elastic bands.short hair may have a thin strip of hair clipped along the incision line. 4. or . Perform scrub and/or paint. . Area to be prepped will vary dependent on incision site. Scalp Prep: 1. . 3.hair removal may or may not occur.Head and Neck Prepsarations A. 2. Management of hair: .Ensure prep solution penetrates through the hair to the scalp and covers all the hair and scalp in the area to be prepped.
Cover the eye with a 4x4 gauze and massage eye gently especially the fornices. forehead and nose on correct side. . paint operative eye. (Note: solution of equal parts of BSS and 10% povidone iodine solution make a 5% solution) 8. forehead and nose on correct side. 2. Repeat going from medial to lateral canthus. Ensure a cap or towel is over the patient’s head to keep hair tucked away. 5. Allow to air dry. cheek. however DO NOT touch the mucosa or the cornea. Going from medial to lateral canthus. paint operative eye. Instill a 5% povidone solution into the eye. 9. 6. Do not touch cornea. Eye Prep: 1. Do not use Chlorhexidine or alcohol solutions. The hairline is considered a contaminated area. clean eyelashes of operative eye with cottontipped applicator dipped in 10% povidone iodine prep solution. cheek. Don sterile gloves. 3. 7.B. 11. Instill NSS into the eye. For patients allergic to iodine. using ½ circle motions above and below eye. Do not scrub lashes. using ½ circle motions above and below eye. Do not blot solution off of the skin. 10. Using just one stroke over eyelashes. use chlorhexidine. Tuck sterile drip towels under patient as necessary to prevent pooling of solution. 4.
. Ensure a cap or towel is over the patient’s hair. 5. Face Prep: 1. Do not remove eyebrows. 3. and use waterproof tape if necessary to ensure hair is tucked away. 4. Perform paint.C. 2. The hairline is considered a contaminated area. Prep the external ear if necessary. Begin prep at incision site and extend to the periphery of hairline and neck.
Perform paint. and use waterproof tape if necessary to ensure hair is tucked away. Extend the prep to the edge of the hairline. Ensure a cap or towel is over the patient’s hair. 4. Place absorbent cotton into the external ear canal. 5. Ear Prep: 1.D. Cleanse the external ear. The hairline is considered a contaminated area. 3. . Remove the absorbent cotton from the external ear canal. face and jaw. 2. 6.
2. and chest almost to the nipple line. Neck Prep: 1. Ensure a cap or towel is over the patient’s hair and use waterproof tape if necessary to ensure hair is tucked away. 3. . tops of the shoulders. Perform scrub.E. The area to be prepped includes the neck laterally to the table line and up to the mandible.
Be careful not to pull the patient’s shoulder laterally to expose the scapular area to avoid dislocation and further injury to the patient. 2. upper arm. 3.Torso Preparations A. Shoulder Prep: 1. Perform scrub. scapula and axilla on the affected side. . neck and shoulder. Area to be prepped includes the chest. Elevate the patient’s arm prior to proceeding with prep. Prep the axilla last.
If incision is in axilla. 2. to include an area beyond the drape fenestration. Prep the axilla last. 5. including the upper arm to elbow circumferentially and the axilla of the operative side. 7.B. 4. 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. Perform scrub. 6. Skin prep for thoracic surgery requires an extension bilaterally of the boundaries for radical breast surgery. use a separate sponge for the axilla. 3. Chest/Breast Prep: 1. prep the breast from the incision area. For a breast biopsy. .
Perform scrub. Abdominal Prep: 1. Area that may be required to be included is from nipple line to upper 1/3 of thighs. 3. . Laparoscopic cholecystectomy).C. Discard applicators after use. inguinal hernia repair). Umbilicus is prepped first using sterile cotton-tipped applicators dipped in antiseptic solution. 2. table level left to table level right (ie. Area to be prepped will vary depending on surgery to be performed (ie appendectomy.
Back procedure: area to be prepped includes the border of the OR table on both sides. E. Back procedure if patient is prone: area to be prepped includes from neck to sacrum. 3. Perform scrub. back and mid-abdominal wall. Back Prep: 1. Flank: 1. Area to be prepped includes shoulder to iliac crest. Frontal prep depends on accessibility when patient is in lateral position. Perform scrub. 2. 2.D. .
. .Prep labia majora using downward strokes. 4. Ensure towel or impervious drape is removed following completion of the preparation. including perineum. Discard sponge when periphery reached.F. Discard sponge when periphery reached. . 3. Do not use Chlorhexidine or alcohol solutions. and thighs as follows: . Prep anus last. 5.Start prep at the pubis and prep to iliac crest using back and forth strokes.Use fresh sponge to prep inner thigh of second leg starting at labia majora and moving laterally using back and forth strokes. 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. . Perform scrub. Next: prep vaginal vault using a separate sponge mounted on a forcep. 2. Place drip towel or impervious drape under buttocks to prevent prep solution from pooling under the patient’s coccyx. labia. 6. First: prep pelvis.
3 .First: Prep perineal area including pelvis. perineum. 2. . Abdominal/Perineal Prep: 1. prep the abdomen. Perform scrub. The anus is prepped last being the most contaminated area. 4. anus and thighs. 2. Prep the anus last – do not penetrate the anus itself. Perianal Prep: 1. H. 4. labia. Next: Using a separate prep set-up. 3. Perineal and abdominal prep shall not be performed simultaneously. Perform scrub. Begin prep outside anal mucosa and extend outward in all directions. Prep area surrounding anus first.G.
Extremity Skin Preparations Extremities: (General) 1. Elevate limb for prep. 3. 2. Perform scrub. A towel tucked around a tourniquet cuff absorbs excess solution. . 4. Place a drip sheet under the operative arm/leg prior to prep. Ensure drip sheet is removed after completion of surgical skin prep.
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.
. 3. 4. 2. if not part of the surgical site. Should a surgeon request to pack a stoma. Seal off with a sterile adhesive drape. Prep gently and last if stoma is part of the surgical incision. Place a soaked sponge over the stoma before peripheral tissues are prepped and discard at completion of prep.Special Preparations Stomas: 1. ensure that a radiopaque Betadine soaked sponge is used. Cover the stoma with sterile clear plastic adhesive dressing to prevent fecal material from entering the surgical wound.
Graft Sites 1. 3. Position drip towels/drip sheet as appropriate. Wear appropriate PPE (gloves. denuded or traumatized skin. 3. . 4. Do not use irritating solutions on denuded areas. Use drip sheet under the wound. Prep donor site first. Irrigate wound as necessary with sterile normal saline. mask and eyewear). Use a colorless antiseptic on the donor site so that the graft vascularity may be evaluated post op. 6. Prep surrounding intact skin. 5. Use only normal saline to prep burned. 7. May need to cover the wound with sterile gauze while prepping surrounding areas. 2. 2.Traumatic Wounds: 1. Use separate set-ups for recipient and donor sites.
increasing respiratory rate. Clinical signs: Rapid weak pulse. cold clammy skin. . thirst.POST OPERATIVE COMPLICATIONS A. Circulatory Hemorrhage – Bleeding internally or externally. lowered BP. Preventive intervention: Early recognition of signs. . restlessness. insecure ligation of blood vessels.cause: disruption of sutures. pallor. reduced urine output.
factors causing increased blood coagulability (eg. Preventive Interventions: Early ambulation. adequate fluid intake. . pelvis. shock (tachycardia. . leg exercises.cause: venous stasis. signs and prevention: same as thrombus.Thrombus – Blood clot attached to wall of vein or artery (most commonly the leg veins).cause. antiemboli stockings. vein injury resulting from surgery of legs. abdomen. Embolus – Clot that has moved from its site of formation to another area of the body. low BP). Clinical signs: Sudden chest pain. . use of estrogen). SOB. cyanosis.
Preventive Intervention: Monitoring of fluid intake and output. bladder distention. Clinical signs: Fluid intake larger than output. inability to void or frequent voiding of small amounts. . interventions to facilitate voiding. vagina). handling of tissues during surgery on adjacent organs (rectum. suprapubic discomfort.B.cause: depressed bladder muscle tone from narcotics & anesthetics. restlessness. . Urinary Urinary retention – Accumulation of urine in the bladder and inability of the bladder to empty itself.
Urinary tract infection – Inflammation of the bladder. cloudy urine. early ambulation. good perineal hygiene. . . Clinical signs: Burning sensation when voiding. lower abdominal pain.cause: immobilization and limited fluid intake. Preventive Intervention: Adequate fluid intake. early ambulation. urgency.
early ambulation. analgesics (decreased intestinal motility). within 48 hours after solid diet started). abdominal distention. and discomfort. Gastrointestinal Constipation – Infrequent or no stool passage for abnormal length of time (eg.C. high-fiber diet. .cause: lack of dietary roughage. . Clinical signs: Absence of stool elimination. Preventive Interventions: Adequate fluid intake.
full fluids and regular diet when peristalsis returns. abdominal distention. . anxiety. then clear fluids. ingesting fluids or foods before return of peristalsis. certain medications. Preventive Intervention: IV fluids until peristalsis returns. retching or gagging.Nausea and Vomiting -cause: pain. Clinical signs: Complaints of feeling sick to the stomach.
wound odor.D.. Wound Wound infection – Inflammation and infection of incision or drain site. tenderness. lab analysis of wound swab identifies causative microorganism. Clinical signs: Purulent exudates. . redness. . elevated body temp.cause: poor aseptic technique.
b. An open wound is a break in the skin or in a mucous membrane.usually result from external physical forces. either internal or external. .WOUND .can be classified as open or closed. A closed wound involves underlying tissues without a break in the skin or a mucous membrane. . a.is a break in the continuity of a tissue of the body. .
Lacerations – jagged. metal edges. .degree of bleeding depends on the depth and extent of a cut 3. irregular or blunt breaks or tears in the soft tissues. .commonly result from falls or the handling of rough objects.bleeding may be rapid and extensive 4. nails and splinters. . Incisions – cuts in body tissues commonly caused by knives.TYPES OF WOUNDS 1. . . broken glass.bleeding is usually minor. 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. 2. Abrasions – results from scraping (abrading) the skin and thereby damaging it. Punctures – produced by bullets and pointed objects such as pins. . or other sharp objects.
but most ulcers are caused by external forces such as pressure. Ulcers . roughly circular area. .often has destruction of tissue in a broad. .g.Second-degree wounds include damage to the dermis and produce blisters. . 6.First-degree burns are superficial and red.can be made by innate destructive processes. dead tissue. heavy machinery. shearing.usually followed by heavy bleeding. guns and explosives.ischemia is then created below the surface where the ulcer is seen.g.made by external destructive energy (e. Burns .. Avulsions – involve the forcible separation or tearing of tissue from the victim’s body.commonly caused by animal bites and accidents involving motor vehicle.Third-degree wounds go deeper than the dermis and produce dry. friction and moisture. . 7.. . heat) or by external chemicals (e. . .5. acid). .
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 .
Permit air to reach the wound. b. 2. Air and water occlusive dressing c. Does not require tape d. Self adhesive b. Can be left in place up to one week . Chief advantage is they facilitate wound assessment without removing the dressing. Transparent dressing a.Types Of Dressing 1. Dry gauze dressing . 3. Wet gauze dressing –retains moisture while it removes drainage from the wound. Non Absorbent 4. Less bulky than gauze c. Hydrocolloid dressing a.
Tape or Montgomery straps 2. Irrigation pack and solution g. Sterile and clean gloves i. Eye shield or face guard h. Gather supplies and wash hands b. when the wound requires assessment or care. Sterile saline or water f. Sterile dressings d. Dressings are changed per doctor's orders.Changing of Dressing 1. . Waterproof bed pads c. Supplies and equipment needed a. and when they become loose or saturated with drainage. Plastic bag or basin e.
odor. being careful not to tear the wound or dislodge any drains.3. Place waterproof pad under patient and prepare plastic bag as receptacle. Remove gloves and dispose in plastic bag. f. d. Gently loosen tape toward the wound while supporting the skin around the wound or untie Montgomery straps. to prevent discomfort to the patient and/or to maintain integrity of sutures. Position the patient and expose the area to be redressed. . Establish a sterile field. e. color. h. Open all sterile equipment and supplies and place within the sterile field. Put on clean non-sterile exam gloves. Remove the dressing. c. b. Put on sterile gloves. i. Uncap sterile saline or other solution as ordered. and consistency of drainage g. Use sterile saline to moisten dressing if it is sticking to the wound. Explain procedure to patient a. Assess amount.
Enter the date and time of the procedure. consistency. 7. Lay inner dressing over wound ensuring the dressing extends past the edge of the wound. . 5. Cover all inner dressings with a large out dressing.Applying a Sterile Dressing 1. 8. Enter a description of the wound's color. 6. Remove gloves and place in disposal bag CAUTION: Tape should not form a constricting band around the wound or extremity. 9. CAUTION: Some wounds must be kept moist. Close and dispose of plastic bag with used supplies. and will require the use of "wet to dry" dressings. 2. The inner dressings that touch the wound directly will be dampened with a solution (usually normal saline) before application. All other dressings will overlap each other and cover entire wound 3. and amount of drainage. Reposition and cover patient. 4. Tape the dressing. b. odor. The outer dressings are applied dry. Document wound care and all assessments on the appropriate form a. Wash hands. Example: abdominal evisceration.
Discard the gauze. Discard the gauze. • Third stroke . Do not use the same swab/gauze to clean the entire wound .Continue this procedure alternating sides of the wound. .cleanse the skin on other side of wound. Linear wound • First stroke .starting at the center of the wound.cleanse the skin area on one side next to the wound.Continue this procedure. 2. working outward until wound is clean. Do not cross back to the center of wound. Circular wound • First stroke . • Second stroke . working away from the wound until clean. . wiping from top to bottom.cleanse the area directly over the wound by wiping from the top to bottom. wiping from top to bottom. Discard the gauze.Cleansing the Wound 1. wipe the wound area with an outward spiral motion.
pour a mall amount of the liquid into waste receptacle. 5. Put on sterile gloves and eye shield or face guard. non-iodine-based solution may be used (Hibiclens. if available. Betadine not generally used in irrigation unless severely contaminated. . To prevent contamination and to clean the bottle rim. this step is not necessary. 7. 2. If the seal of the bottle has not been broken. DO NOT force solution into wound pockets. Use enough force to flush out debris but do not squirt or splash fluid 6. 3. Fill the syringe with solution from the sterile basin. CAUTION: If Betadine (iodine) is being used. check to ensure patient does not have allergies to it. Hold the tip of the syringe just above top end of wound and force fluid into the wound slowly and continuously. phisohex.Irrigating the Wound 1. An alternate. hydrogen peroxide). gently pat dry the edges of the wound. Work from cleanest to most contaminated areas. Using sterile gauze. Continue irrigating until solution draining from bottom end of wound is clear. Pour irrigating solution into basin with the label facing the palm 4. Irrigate all portions of the wound.
urinary. 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 urinary diversion. or respiratory tract onto the skin. or. Different kinds of ostomies are named after their anatomic location. . A person who has an ostomy uses a plastic pouch (appliance) to cover the stoma and collect the stool (effluent) or urine. large intestine to the abdominal wall) and ureterostomy.OSTOMY An ostomy is an opening for the gastrointestinal. is a stoma on the outer abdominal wall for drainage of urine.
2. . 3. gently remove the old wafer from the skin. At the same time.Ostomy Appliance Procedure 1. according to facility protocol. use adhesive remover or rubbing alcohol. Position the patient so that no skin folds occur along the line of the stoma. use the other hand to hold tension on the skin in the opposite direction of the pull. 4. 8. Wash hands and don clean gloves. With one hand. beginning at the top and proceeding in a downward direction. If resistance is encountered and the wafer is difficult to remove. 6. If the pouch is drainable. Fold down the linen to expose the ostomy site. 5. open it by removing the clamp and unrolling it at the bottom. Save the clamp for re-use (note that some pouches cannot be drained). places a clean towel across the patient’s abdomen under the existing pouch. 7. Empty the existing ostomy pouch into a bedpan.
Inspect stoma and peristomal skin. 15.9. Use warm water and mild soap to cleanse stoma and surrounding skin.5–3 cm) larger than the circumference of the stoma. Remove gloves and wash hands. dispose of it according to agency protocol. Measure the stoma from side to side (approximating the circumference). 17. c. 13. If the pouch is nondrainable. Measure the size of the stoma in one of the following ways: a. 12. Allow the area to dry. b. Place the old pouch and wafer in a plastic bag for disposal. Re-use a previously cut template. 11. 14. Wafer opening is approximately 1/16 to 1/8 inch (1. Use a standard stoma measuring guide placed over the stoma. . 10. Report excess bleeding to the physician. 16. Places a clean 4×4 gauze pad over the stoma. Trace the size of the opening obtained in Step 14 onto the paper on the back of the new wafer. cuts the opening.
When the seal is complete.18. applies skin barrier powder or paste. place the wafer on first.g. Some resources suggest first holding the wafer between the palms of the hands to warm the adhesive ring. Don clean procedure gloves. NOTE: Some ostomy wafers come with an outer ring of tape attached. If using a one-piece pouch. fold the end of the pouch over the clamp and close the clamp. Remove the gauze. do not remove the backing on this tape until the wafer is securely positioned (Steps 22–24). wipes around stoma with skin-prep. If ostomy skin care products are to be used. make sure the bag is pointed toward the patient’s feet. 19. apply them at this time (e.. Peel the paper off the wafer. . a. 21. 20. b. applies extra adhesive paste). For an open-ended pouch. c. If using a two-piece system. 22. Center the wafer opening around the stoma and gently press down. listening for a “click” to ensure it is secure. attaches the bag following manufacturer’s instructions. If so.
26. Dispose of used ostomy pouch following agency policy for biohazardous waste.23. . Some sources also suggest taping down the edges of the wafer. 24. Remove gloves and wash hands. making it adhere better. Return patient to a comfortable position. Ask the patient to place her hand over the newly applied wafer to warm the adhesive ring. 25.
color.Nursing Responsibilities Assessment. • the patient’s knowledge and understanding of ostomy care. and the condition of periostomal skin from the patient’s record to compare with present findings. the nurse should assess: • the color of the stoma. consistency. Prior to and during the procedure. • the feces for amount. . • the periostomal skin for irritation and redness. presence of blood or pus. • the stoma for swelling. Acquire baseline data on the size and kind of stoma. the character of the effluent.
and in some cases. including tissues. or sheet to protect the skin. towel. • cleaning materials. in the form of a spray. . The nurse should assemble the following equipment: • nonsterile gloves. • adhesive with brush to apply it to the bag if needed.Planning. to protect hands. wash cloth. • gauze pad to cover the stoma. • a skin barrier. • measuring guide (stoma guidestrip) to measure the stoma. disc. • a water-proof bag for the soiled appliance to minimize odor. • a deodorant for a non-odorproof colostomy bag. • scissors if the appliance does not have a precut opening. mild soap. warm water. • clamp.
Explain the procedure to the patient and/or family member.) 9. 5. Assist the patient to a comfortable position. where the patient can learn to care for his/her ostomy as he/she would at home. Provide privacy. Unfasten the belt and check the method of adhesion. Communicate acceptance and support of the patient. 3. 6.Intervention. 8. Dry the area thoroughly by patting with a towel. 4. 7. and expose only the stoma area. Changing an ostomy appliance is outlined in the following procedure: 1. (Check agency policy on use of soap since soap may be irritating to the skin. either sitting or lying. Empty the effluent in the pouch. 2. Remove the appliance. preferably in the bathroom. Cleanse the periostomal skin and stoma with warm water and soap. Rationale: Excessive rubbing may abrade the skin. peeling the bag off slowly while holding the patient’s skin taut. .
The opening of the faceplate should be approximately 1/16” larger than the stoma. Discard or cleanse the bag. Measure the effluent if ordered. 11. 16. Remove and discard gloves. • condition of stoma and peristomal skin • patient’s response • amount. or a karaya product. rinse. Rationale: Any seepage from the stoma will be absorbed in the tissue or gauze pad.10. 13. 648 12. Check the fit of the appliance. Wash soiled belt with warm water and mild soap. and dry. 15. Refer to the manufacturer’s instructions for a specific produce. Document in patient’s record. or liquid such as Skin Prep. color. a spray. Rationale: Close fit of the barrier (faceplate) prevents contact of skin with effluent. and consistency of drainage . wash hands. 14. Prepare and apply the skin barrier which may be in the form of a disc or sheet such as Stomahesive. Place a piece of tissue or gauze pad over the stoma. Measure the size of the guidestrip.
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 .
Sterile towels. Other supplies and equipment as required by physician (and available). 10. . Equipment and supplies used in a venous cutdown are listed below. 8. 3. 4. 7. Supplies for prepping and dressing the wound area. Scalpel handle and blades. 6. Sterile gloves. 2. Hemostats. mask. Suture materials. 1. Equipment and Supplies. Scissors (vascular and suture).CUT-DOWN PROCEDURE a. Intravenous setup. 9. if required. 5. Splint.
3. . 2. Basilic vein below the elbow. Some suggested sites are listed below.b. Site. 1. Saphenous vein above the ankle. 4. Cephalic vein below the elbow. Several sites may be chosen depending on the condition of the patient and the fluid to be infused. Basilic vein above the elbow.
Prepare and stabilize the site. Make a transverse cut and dissect the tissue until the vein is visible (see figure 3. Assemble the equipment and supplies. Wash your hands. gently spread the underlying tissue to fully expose the vein. . 1. 2. Explain the procedure to the patient. Procedure for the Cutdown. 4. 6. 3. Figure 3-7. 5. Open incision for venous cutdown.7).c. Using a curved hemostat. Apply/inject a local anesthetic so the patient will not feel the incision.
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). . Thread under vein. 8. Tie both threads and pull in opposite directions.7. Figure 3-8.
(9) Nick the vein with a scalpel (or cut with vascular scissors). . Nick vein with scalpel. (See figure 3-9) Figure 3-9.
.10. Insert the proper size plastic catheter into the exposed vein (to near the catheter hub) and secure (see figure 3-10). Figure 3-10. Insert catheter into vein.
15. date and time of insertion. 12. Outer tape should show catheter size. Suture incision. Figure 3-11. Attach catheter to previously prepared infusion set and close the wound. . 14. The procedure must be documented (usually in Nursing Notes).11. 13. and inserter's initials. Apply a sterile dressing and tape the catheter in place. Suture the incision and apply an antibiotic ointment (see figure 3-11). Physician will specify when to remove the skin sutures.
and to drink hot liquids and fruit juices especially prune juice. 4. 3. Avoid fasting. Limit carbonated beverages. such as cabbage. . For diarrhea. 6.Colostomy Care Do’s and Don’ts Do’s 1. Don't take any medication unless you know it will dissolve quickly and be fully absorbed. Avoid eating gas-forming foods. Regular exercise. 2. 5. Don’ts 1. 5. Provide privacy. 2. Don’t give blood. encourage oral intake of fluids and bland food. Don’t put things into the stoma. 4. When constipated. onions and cauliflower. 6. instruct client to increase daily fluid intake. 3. beans. Don’t eliminate salt from diet. the use of drinking straws and chewing gum. Client should be encouraged to defecate when the urge is recognized.
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