CONSENT A.

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.

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Peri-Operative Nursing
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. Nurses’ Role During Surgery Pre-Operative Phase a. f. g. e. d. Obtaining the medical or surgical history during endorsements is very important in terms of knowing the patient. Alleviate the patient’s anxiety about the procedure as well as coordination with other health team members such as the doctor. Communicate with the patient’s folks in times of emergencies during the procedure as well as after the procedure. .A. b. Verify the data with the chart. Obtain initial vital signs and other monitoring data essential for the success of the procedure. Make sure that an informed consent is made and the patient and its family fully understand the risks and consequences of the procedure. asking the patient’s of his or her name when he or she is conscious. clergy or orderlies. c. Ensure the patient’s identity is correct by checking the identity band. Ensure the patient’s safety by properly checking the side rails and support while transporting in a stretcher.

e.Intra-Operative Phase a. Properly drape the patient. b. The nurse is also responsible in informing the surgeon that the instruments or sponges have been properly taken out from the procedure. c. Exposing only the body parts involved in the surgery. . The counting of sponges and instruments is done before the initial closure and after procedure. Protect the patient from falls especially during the induction of anesthesia. 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. the nurse is responsible in counting the number of sponges used. Keeping the operative field sterile and free from blood. This must be done with another nurse to help him or her make a proper counting. d. Assist the surgeon during procedure which may involve handing the surgical instruments properly. Upon closure of the operative field.

Teach the patient about caring for the operative site as well as advise the activities that must be done for a faster recovery. Administer medications prescribed after the surgery. Monitor the patient’s vital signs and watch out for side effects of the an anesthesia such as hypothermia and disorientation. . Others may even warrant blood administration for those who suffered a significant amount of blood loss during the surgery. a.Post-Operative Phase a. b. Assess the vital signs of each patient for every 15 minutes for the first hour and every 30 minutes thereafter. c.

Perform surgical scrub and/or paint as applicable for the type of surgery being performed. Ensure surgical site is marked . intestinal stomas. Perform hand hygiene prior to any contact with the patient. sinuses.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. . Peripheral intact skin is prepared before open wounds and body orifices. 3. When performing a surgical skin prep for necrotizing fasciitis: . the vagina or anus should be used once and then discarded. or . using principle of clean to dirty. 3.if skin is intact perform as usual. Expose only the area to be prepared to ensure privacy and warmth of the patient. ulcers. pull foreskin back once prep is completed to prevent compromise to circulation. Retract foreskin if prep involves the penis. For Contaminated Areas: 1. 2. 4. 4.Skin Preparation of Specific Operative Areas GENERAL STEPS FOR ALL TYPES OF SKIN PREPARATIONS: 1. Sponges used to prep open wounds. 2. however treat intact skin carefully due to loss of structure under the skin. Prep the most contaminated area last using separate sponges. 5.

Wash hands and don clean disposable gloves. Razor shaves are not recommended. Stroke against the direction that the hair is growing using short strokes. 3. 2. 5. 4. Use a single use clipper or a clipper with a reusable handle and disposable head. 7. Clean and disinfect the reusable clipper handle after use following manufacturers’ instructions. Discard disposable clipper head into an appropriate sharps container. .Hair Removal: 1. 6. 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.

in skin/anatomical creases. Don sterile gloves. Cleanse the skin in a linear and circular motion.Lift carefully without rubbing or dragging the fabric over the cleaned area. around a tourniquet. 6. 7. Tuck drip towels under patient as necessary to prevent pooling of solution: . Mix an appropriate amount of antiseptic scrub solution with an appropriate amount of warm sterile water in a basin. 5. Perform paint. 2. Remove drip towels by grasping the edges in a manner to prevent the towel edges from contaminating the prepped skin.Open a towel fully and place it over the site. under the patient. Blot cleansed area dry with a sterile towel as follows: . Rinse cleansed area using sterile gauze moistened with sterile water. and . . or near EKG electrodes 4. 3. 8. between the patient and positioning devices. This allows for sudsing action of the antiseptic scrub solution.Scrub and Paint Surgical Skin Prep: 1. under an electrosurgical dispersive electrode.

Ensure prep solution penetrates through the hair to the scalp and covers all the hair and scalp in the area to be prepped.hair removal may or may not occur. 4. 2. 3. or . . Area to be prepped will vary dependent on incision site.Head and Neck Prepsarations A. Perform scrub and/or paint. Scalp Prep: 1.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. Management of hair: . .

Don sterile gloves. 2. Do not touch cornea. 7. 4. For patients allergic to iodine. using ½ circle motions above and below eye. forehead and nose on correct side. paint operative eye. 5. Do not scrub lashes. Repeat going from medial to lateral canthus. 9. Instill NSS into the eye. however DO NOT touch the mucosa or the cornea. using ½ circle motions above and below eye. Do not use Chlorhexidine or alcohol solutions. cheek. Cover the eye with a 4x4 gauze and massage eye gently especially the fornices. Eye Prep: 1. forehead and nose on correct side. 6. use chlorhexidine. Using just one stroke over eyelashes. paint operative eye. Instill a 5% povidone solution into the eye. Allow to air dry. . Going from medial to lateral canthus. Tuck sterile drip towels under patient as necessary to prevent pooling of solution. cheek. 11. 3.B. 10. Do not blot solution off of the skin. Ensure a cap or towel is over the patient’s head to keep hair tucked away. The hairline is considered a contaminated area. clean eyelashes of operative eye with cottontipped applicator dipped in 10% povidone iodine prep solution. (Note: solution of equal parts of BSS and 10% povidone iodine solution make a 5% solution) 8.

Prep the external ear if necessary. 3. The hairline is considered a contaminated area. 2. and use waterproof tape if necessary to ensure hair is tucked away. Face Prep: 1. Perform paint. Ensure a cap or towel is over the patient’s hair. Do not remove eyebrows.C. . 4. Begin prep at incision site and extend to the periphery of hairline and neck. 5.

Place absorbent cotton into the external ear canal. 2. face and jaw. 3. Remove the absorbent cotton from the external ear canal. Ensure a cap or towel is over the patient’s hair. 4. . The hairline is considered a contaminated area. Cleanse the external ear. Perform paint. 6.D. Ear Prep: 1. and use waterproof tape if necessary to ensure hair is tucked away. 5. Extend the prep to the edge of the hairline.

Ensure a cap or towel is over the patient’s hair and use waterproof tape if necessary to ensure hair is tucked away.E. 3. . Perform scrub. tops of the shoulders. and chest almost to the nipple line. Neck Prep: 1. The area to be prepped includes the neck laterally to the table line and up to the mandible. 2.

Prep the axilla last. Elevate the patient’s arm prior to proceeding with prep. upper arm. Perform scrub. scapula and axilla on the affected side. Shoulder Prep: 1. 3. . Area to be prepped includes the chest. 2. neck and shoulder. 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.

B. 7. 4. . Perform scrub. use a separate sponge for the axilla. 3. Chest/Breast Prep: 1. For a breast biopsy. 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. If incision is in axilla. Prep the axilla last. 2. Skin prep for thoracic surgery requires an extension bilaterally of the boundaries for radical breast surgery. 6. including the upper arm to elbow circumferentially and the axilla of the operative side. Prep both sides of the chest for a bilateral procedure. prep the breast from the incision area. to include an area beyond the drape fenestration. 5.

Umbilicus is prepped first using sterile cotton-tipped applicators dipped in antiseptic solution. Discard applicators after use. Laparoscopic cholecystectomy). . Area that may be required to be included is from nipple line to upper 1/3 of thighs. Perform scrub. Abdominal Prep: 1. inguinal hernia repair). Area to be prepped will vary depending on surgery to be performed (ie appendectomy. 3. table level left to table level right (ie.C. 2.

Frontal prep depends on accessibility when patient is in lateral position. Back procedure: area to be prepped includes the border of the OR table on both sides. Perform scrub. Back procedure if patient is prone: area to be prepped includes from neck to sacrum. Area to be prepped includes shoulder to iliac crest. Back Prep: 1. Perform scrub. . back and mid-abdominal wall. E. 2. Flank: 1.D. 3. 2.

labia. . 2. . 6. Do not use Chlorhexidine or alcohol solutions. Next: prep vaginal vault using a separate sponge mounted on a forcep. Prep anus last. 5. and thighs as follows: .F. Place drip towel or impervious drape under buttocks to prevent prep solution from pooling under the patient’s coccyx. . perineum. First: prep pelvis. Discard sponge when periphery reached. 4. including perineum.Prep labia majora using downward strokes. Vaginal Prep: 1.Use fresh sponge to prep inner thigh of second leg starting at labia majora and moving laterally using back and forth strokes. 3.Start prep at the pubis and prep to iliac crest using back and forth strokes. Discard sponge when periphery reached. Ensure towel or impervious drape is removed following completion of the preparation. . Perform scrub.Use fresh sponge to prep inner thigh of first leg starting at labia majora and moving laterally using back and forth strokes.

2. Perform scrub. .First: Prep perineal area including pelvis. 4. Perianal Prep: 1. Begin prep outside anal mucosa and extend outward in all directions. 4. Prep the anus last – do not penetrate the anus itself. Prep area surrounding anus first. H. Next: Using a separate prep set-up. 3. 3 . anus and thighs. labia. prep the abdomen. perineum. 2. The anus is prepped last being the most contaminated area. Perform scrub.G. Abdominal/Perineal Prep: 1. Perineal and abdominal prep shall not be performed simultaneously.

3. Perform scrub. Ensure drip sheet is removed after completion of surgical skin prep. . Place a drip sheet under the operative arm/leg prior to prep. Elevate limb for prep. 4. 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.

if not part of the surgical site. 2. 4. Seal off with a sterile adhesive drape. 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. Prep gently and last if stoma is part of the surgical incision. . 3.Special Preparations Stomas: 1. Should a surgeon request to pack a stoma. Place a soaked sponge over the stoma before peripheral tissues are prepped and discard at completion of prep.

mask and eyewear). Do not use irritating solutions on denuded areas. Graft Sites 1. 4. denuded or traumatized skin. Use separate set-ups for recipient and donor sites. Use drip sheet under the wound. Position drip towels/drip sheet as appropriate. Wear appropriate PPE (gloves. Use a colorless antiseptic on the donor site so that the graft vascularity may be evaluated post op. . Irrigate wound as necessary with sterile normal saline. 3. Prep surrounding intact skin. 5. Prep donor site first. 3. 2. 6. 2. 7.Traumatic Wounds: 1. May need to cover the wound with sterile gauze while prepping surrounding areas. Use only normal saline to prep burned.

reduced urine output. Circulatory Hemorrhage – Bleeding internally or externally. pallor. Preventive intervention: Early recognition of signs. .POST OPERATIVE COMPLICATIONS A. thirst. Clinical signs: Rapid weak pulse. restlessness.cause: disruption of sutures. lowered BP. insecure ligation of blood vessels. increasing respiratory rate. . cold clammy skin.

use of estrogen). signs and prevention: same as thrombus. low BP). .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.cause: venous stasis. . Preventive Interventions: Early ambulation. shock (tachycardia. adequate fluid intake. leg exercises. Clinical signs: Sudden chest pain. factors causing increased blood coagulability (eg. SOB. vein injury resulting from surgery of legs. cyanosis. antiemboli stockings. pelvis.cause. abdomen.

bladder distention. suprapubic discomfort. Urinary Urinary retention – Accumulation of urine in the bladder and inability of the bladder to empty itself.cause: depressed bladder muscle tone from narcotics & anesthetics. handling of tissues during surgery on adjacent organs (rectum. Clinical signs: Fluid intake larger than output. interventions to facilitate voiding.B. restlessness. . . vagina). inability to void or frequent voiding of small amounts. Preventive Intervention: Monitoring of fluid intake and output.

early ambulation. . cloudy urine. urgency. good perineal hygiene. Preventive Intervention: Adequate fluid intake. early ambulation.cause: immobilization and limited fluid intake.Urinary tract infection – Inflammation of the bladder. . Clinical signs: Burning sensation when voiding. lower abdominal pain.

within 48 hours after solid diet started).cause: lack of dietary roughage. and discomfort. analgesics (decreased intestinal motility). Preventive Interventions: Adequate fluid intake. early ambulation. abdominal distention.C. Clinical signs: Absence of stool elimination. . Gastrointestinal Constipation – Infrequent or no stool passage for abnormal length of time (eg. high-fiber diet. .

. Preventive Intervention: IV fluids until peristalsis returns. Clinical signs: Complaints of feeling sick to the stomach.Nausea and Vomiting -cause: pain. then clear fluids. ingesting fluids or foods before return of peristalsis. anxiety. retching or gagging. abdominal distention. full fluids and regular diet when peristalsis returns. certain medications.

elevated body temp. .D.cause: poor aseptic technique. Clinical signs: Purulent exudates.. redness. wound odor. Wound Wound infection – Inflammation and infection of incision or drain site. tenderness. . lab analysis of wound swab identifies causative microorganism.

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. . .WOUND . a. b. either internal or external. An open wound is a break in the skin or in a mucous membrane.usually result from external physical forces.can be classified as open or closed. .

TYPES OF WOUNDS 1. nails and splinters. metal edges. but the puncturing object may penetrate deeply into the body and may damage organs and soft tissues and sever internal bleeding. . .bleeding is usually minor. Lacerations – jagged. Abrasions – results from scraping (abrading) the skin and thereby damaging it. Punctures – produced by bullets and pointed objects such as pins. .commonly result from falls or the handling of rough objects. broken glass.bleeding may be rapid and extensive 4. irregular or blunt breaks or tears in the soft tissues. or other sharp objects. 2. .bleeding is limited to oozing of blood from ruptured small veins and capillaries. . . Incisions – cuts in body tissues commonly caused by knives.degree of bleeding depends on the depth and extent of a cut 3.

made by external destructive energy (e.commonly caused by animal bites and accidents involving motor vehicle. . . . Ulcers . . .can be made by innate destructive processes. but most ulcers are caused by external forces such as pressure. dead tissue.Second-degree wounds include damage to the dermis and produce blisters.often has destruction of tissue in a broad.. acid).ischemia is then created below the surface where the ulcer is seen.First-degree burns are superficial and red. Avulsions – involve the forcible separation or tearing of tissue from the victim’s body. . . 7. 6.g.g. heat) or by external chemicals (e. shearing.Third-degree wounds go deeper than the dermis and produce dry. . Burns .usually followed by heavy bleeding. roughly circular area. heavy machinery.. friction and moisture. guns and explosives.5.

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 .

Hydrocolloid dressing a. 2. Chief advantage is they facilitate wound assessment without removing the dressing.Permit air to reach the wound. Air and water occlusive dressing c. Wet gauze dressing –retains moisture while it removes drainage from the wound.Types Of Dressing 1. Self adhesive b. Less bulky than gauze c. Transparent dressing a. Dry gauze dressing . 3. Does not require tape d. Non Absorbent 4. Can be left in place up to one week . b.

Plastic bag or basin e. . Irrigation pack and solution g.Changing of Dressing 1. Waterproof bed pads c. Sterile and clean gloves i. Tape or Montgomery straps 2. Sterile dressings d. Gather supplies and wash hands b. Dressings are changed per doctor's orders. and when they become loose or saturated with drainage. when the wound requires assessment or care. Eye shield or face guard h. Supplies and equipment needed a. Sterile saline or water f.

Remove gloves and dispose in plastic bag. Gently loosen tape toward the wound while supporting the skin around the wound or untie Montgomery straps. odor. to prevent discomfort to the patient and/or to maintain integrity of sutures. being careful not to tear the wound or dislodge any drains. Assess amount. Use sterile saline to moisten dressing if it is sticking to the wound. Put on sterile gloves. Position the patient and expose the area to be redressed. Put on clean non-sterile exam gloves. b. Explain procedure to patient a. Uncap sterile saline or other solution as ordered. d. i. f.3. Open all sterile equipment and supplies and place within the sterile field. Place waterproof pad under patient and prepare plastic bag as receptacle. color. h. . c. and consistency of drainage g. e. Remove the dressing. Establish a sterile field.

2. . and amount of drainage. Enter the date and time of the procedure. The inner dressings that touch the wound directly will be dampened with a solution (usually normal saline) before application. Lay inner dressing over wound ensuring the dressing extends past the edge of the wound. Document wound care and all assessments on the appropriate form a. consistency. Tape the dressing. The outer dressings are applied dry. and will require the use of "wet to dry" dressings. 8. 4. b. All other dressings will overlap each other and cover entire wound 3. odor. Wash hands. Enter a description of the wound's color. 7. Close and dispose of plastic bag with used supplies.Applying a Sterile Dressing 1. Example: abdominal evisceration. 9. Remove gloves and place in disposal bag CAUTION: Tape should not form a constricting band around the wound or extremity. 5. Cover all inner dressings with a large out dressing. 6. Reposition and cover patient. CAUTION: Some wounds must be kept moist.

Do not use the same swab/gauze to clean the entire wound . wiping from top to bottom. 2. working outward until wound is clean. wipe the wound area with an outward spiral motion. Discard the gauze. .Continue this procedure alternating sides of the wound. working away from the wound until clean. wiping from top to bottom. Do not cross back to the center of wound. • Third stroke .Continue this procedure.cleanse the area directly over the wound by wiping from the top to bottom. Discard the gauze. Linear wound • First stroke . • Second stroke .Cleansing the Wound 1.starting at the center of the wound. Circular wound • First stroke . . Discard the gauze.cleanse the skin area on one side next to the wound.cleanse the skin on other side of wound.

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. 5. non-iodine-based solution may be used (Hibiclens. gently pat dry the edges of the wound. 7. Continue irrigating until solution draining from bottom end of wound is clear. To prevent contamination and to clean the bottle rim. phisohex. if available. Using sterile gauze. 3. Betadine not generally used in irrigation unless severely contaminated. pour a mall amount of the liquid into waste receptacle. check to ensure patient does not have allergies to it. If the seal of the bottle has not been broken. Work from cleanest to most contaminated areas. this step is not necessary. Hold the tip of the syringe just above top end of wound and force fluid into the wound slowly and continuously. Pour irrigating solution into basin with the label facing the palm 4. Irrigate all portions of the wound. An alternate. DO NOT force solution into wound pockets.Irrigating the Wound 1. 2. CAUTION: If Betadine (iodine) is being used. Fill the syringe with solution from the sterile basin. . hydrogen peroxide).

Different kinds of ostomies are named after their anatomic location.OSTOMY An ostomy is an opening for the gastrointestinal. A person who has an ostomy uses a plastic pouch (appliance) to cover the stoma and collect the stool (effluent) or urine. or. urinary. or respiratory tract onto the skin. is a stoma on the outer abdominal wall for drainage of urine. or urinary diversion. . large intestine to the abdominal wall) and ureterostomy. 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.

places a clean towel across the patient’s abdomen under the existing pouch. according to facility protocol. 6. Wash hands and don clean gloves. Empty the existing ostomy pouch into a bedpan. At the same time. 5. use the other hand to hold tension on the skin in the opposite direction of the pull. 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). 2. beginning at the top and proceeding in a downward direction. 8. Fold down the linen to expose the ostomy site. If resistance is encountered and the wafer is difficult to remove. . use adhesive remover or rubbing alcohol. gently remove the old wafer from the skin.Ostomy Appliance Procedure 1. 7. open it by removing the clamp and unrolling it at the bottom. If the pouch is drainable. 3. With one hand. 4.

cuts the opening. Use warm water and mild soap to cleanse stoma and surrounding skin. 16. Inspect stoma and peristomal skin. .5–3 cm) larger than the circumference of the stoma. Wafer opening is approximately 1/16 to 1/8 inch (1. 10. b. 17. 13. Places a clean 4×4 gauze pad over the stoma. dispose of it according to agency protocol. If the pouch is nondrainable. Allow the area to dry. Measure the stoma from side to side (approximating the circumference). Place the old pouch and wafer in a plastic bag for disposal. Trace the size of the opening obtained in Step 14 onto the paper on the back of the new wafer. Remove gloves and wash hands. Report excess bleeding to the physician. 15. Re-use a previously cut template. 11. 12.9. Measure the size of the stoma in one of the following ways: a. 14. Use a standard stoma measuring guide placed over the stoma. c.

NOTE: Some ostomy wafers come with an outer ring of tape attached.g. Don clean procedure gloves. place the wafer on first. make sure the bag is pointed toward the patient’s feet. fold the end of the pouch over the clamp and close the clamp.18. apply them at this time (e. 22. attaches the bag following manufacturer’s instructions. c. applies skin barrier powder or paste. Peel the paper off the wafer. Remove the gauze.. 20. When the seal is complete. . wipes around stoma with skin-prep. If using a one-piece pouch. a. do not remove the backing on this tape until the wafer is securely positioned (Steps 22–24). applies extra adhesive paste). 21. For an open-ended pouch. If using a two-piece system. Some resources suggest first holding the wafer between the palms of the hands to warm the adhesive ring. 19. If so. Center the wafer opening around the stoma and gently press down. listening for a “click” to ensure it is secure. b. If ostomy skin care products are to be used.

25. 26. . 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. Return patient to a comfortable position.23. Remove gloves and wash hands. 24. making it adhere better. Some sources also suggest taping down the edges of the wafer.

.Nursing Responsibilities Assessment. • the stoma for swelling. color. the character of the effluent. • the feces for amount. the nurse should assess: • the color of the stoma. • 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 periostomal skin for irritation and redness. Prior to and during the procedure. presence of blood or pus. Acquire baseline data on the size and kind of stoma. consistency.

disc.Planning. • a deodorant for a non-odorproof colostomy bag. The nurse should assemble the following equipment: • nonsterile gloves. • measuring guide (stoma guidestrip) to measure the stoma. towel. wash cloth. • scissors if the appliance does not have a precut opening. • adhesive with brush to apply it to the bag if needed. and in some cases. including tissues. mild soap. • cleaning materials. • clamp. • a skin barrier. • gauze pad to cover the stoma. • a water-proof bag for the soiled appliance to minimize odor. in the form of a spray. . warm water. to protect hands. or sheet to protect the skin.

Provide privacy. 6. Cleanse the periostomal skin and stoma with warm water and soap. . Explain the procedure to the patient and/or family member. Rationale: Excessive rubbing may abrade the skin. 7. where the patient can learn to care for his/her ostomy as he/she would at home. Communicate acceptance and support of the patient. either sitting or lying. and expose only the stoma area. Empty the effluent in the pouch.) 9. (Check agency policy on use of soap since soap may be irritating to the skin. Changing an ostomy appliance is outlined in the following procedure: 1. 8. 4. 5. Dry the area thoroughly by patting with a towel.Intervention. peeling the bag off slowly while holding the patient’s skin taut. preferably in the bathroom. Remove the appliance. Unfasten the belt and check the method of adhesion. Assist the patient to a comfortable position. 3. 2.

11. Document in patient’s record. Check the fit of the appliance. Wash soiled belt with warm water and mild soap. wash hands. Measure the effluent if ordered. a spray. Prepare and apply the skin barrier which may be in the form of a disc or sheet such as Stomahesive. 13. and dry. 14. and consistency of drainage . rinse. Rationale: Close fit of the barrier (faceplate) prevents contact of skin with effluent. Refer to the manufacturer’s instructions for a specific produce. Discard or cleanse the bag. • condition of stoma and peristomal skin • patient’s response • amount. Place a piece of tissue or gauze pad over the stoma. color. Remove and discard gloves. or liquid such as Skin Prep. Rationale: Any seepage from the stoma will be absorbed in the tissue or gauze pad. 15. 648 12. The opening of the faceplate should be approximately 1/16” larger than the stoma. Measure the size of the guidestrip. 16. or a karaya product.10.

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 .

Other supplies and equipment as required by physician (and available). Intravenous setup. Suture materials. mask. Supplies for prepping and dressing the wound area. Scalpel handle and blades. 3. Equipment and supplies used in a venous cutdown are listed below. 7. 9. 2. 5. Sterile gloves. 1. Sterile towels. Splint.CUT-DOWN PROCEDURE a. 6. Hemostats. . if required. 10. Equipment and Supplies. 4. 8. Scissors (vascular and suture).

Basilic vein above the elbow. Some suggested sites are listed below. . 1. Saphenous vein above the ankle. Several sites may be chosen depending on the condition of the patient and the fluid to be infused. Basilic vein below the elbow. 4.b. 2. Site. Cephalic vein below the elbow. 3.

Explain the procedure to the patient.7). Assemble the equipment and supplies. Wash your hands. 6. 5. gently spread the underlying tissue to fully expose the vein. 2. 4. Procedure for the Cutdown.c. Open incision for venous cutdown. . Using a curved hemostat. Figure 3-7. Make a transverse cut and dissect the tissue until the vein is visible (see figure 3. 3. Apply/inject a local anesthetic so the patient will not feel the incision. 1. Prepare and stabilize the site.

Figure 3-8. . Lift the vein and put two threads of suture under it (see figure 3-8). Tie both threads and pull in opposite directions. 8. Thread under vein.7. Leave enough vein between the two ties to insert the catheter.

Nick vein with scalpel. (See figure 3-9) Figure 3-9.(9) Nick the vein with a scalpel (or cut with vascular scissors). .

Insert the proper size plastic catheter into the exposed vein (to near the catheter hub) and secure (see figure 3-10).10. Figure 3-10. Insert catheter into vein. .

Suture the incision and apply an antibiotic ointment (see figure 3-11). . 15. 14. Physician will specify when to remove the skin sutures. 13. Attach catheter to previously prepared infusion set and close the wound. Suture incision.11. The procedure must be documented (usually in Nursing Notes). Figure 3-11. and inserter's initials. Apply a sterile dressing and tape the catheter in place. Outer tape should show catheter size. date and time of insertion. 12.

6. When constipated. Don’t eliminate salt from diet. Don’t put things into the stoma. the use of drinking straws and chewing gum. 5. beans. 4. onions and cauliflower. encourage oral intake of fluids and bland food. Don’t give blood. Avoid eating gas-forming foods. and to drink hot liquids and fruit juices especially prune juice. For diarrhea. Provide privacy. 5. Client should be encouraged to defecate when the urge is recognized. 3. . Avoid fasting. 3. 2. such as cabbage. Don’ts 1. instruct client to increase daily fluid intake. 2. Regular exercise. Don't take any medication unless you know it will dissolve quickly and be fully absorbed. Limit carbonated beverages. 6. 4.Colostomy Care Do’s and Don’ts Do’s 1.

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