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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
A. Nurses’ Role During Surgery Pre-Operative Phase a. Obtain initial vital signs and other monitoring data essential for the success of the procedure. g. asking the patient’s of his or her name when he or she is conscious. f. b. Verify the data with the chart. e. Communicate with the patient’s folks in times of emergencies during the procedure as well as after the procedure. Ensure the patient’s safety by properly checking the side rails and support while transporting in a stretcher. d. Check the orders and special procedures as well as the indication of a surgical procedure. Ensure the patient’s identity is correct by checking the identity band. Alleviate the patient’s anxiety about the procedure as well as coordination with other health team members such as the doctor. clergy or orderlies. Make sure that an informed consent is made and the patient and its family fully understand the risks and consequences of the procedure. Obtaining the medical or surgical history during endorsements is very important in terms of knowing the patient. c. .
Exposing only the body parts involved in the surgery. c. Upon closure of the operative field. The nurse is also responsible in informing the surgeon that the instruments or sponges have been properly taken out from the procedure. The counting of sponges and instruments is done before the initial closure and after procedure. This must be done with another nurse to help him or her make a proper counting.Intra-Operative Phase a. b. 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. e. Properly drape the patient. Assist the surgeon during procedure which may involve handing the surgical instruments properly. Keeping the operative field sterile and free from blood. d.
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. Teach the patient about caring for the operative site as well as advise the activities that must be done for a faster recovery. c.Post-Operative Phase a. a. Others may even warrant blood administration for those who suffered a significant amount of blood loss during the surgery. b. Monitor the patient’s vital signs and watch out for side effects of the an anesthesia such as hypothermia and disorientation.
if skin is intact perform as usual. Ensure surgical site is marked . 4. Perform surgical scrub and/or paint as applicable for the type of surgery being performed. however treat intact skin carefully due to loss of structure under the skin. ulcers. Expose only the area to be prepared to ensure privacy and warmth of the patient. For Contaminated Areas: 1. 5. 2.Skin Preparation of Specific Operative Areas GENERAL STEPS FOR ALL TYPES OF SKIN PREPARATIONS: 1. or .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. . 2. intestinal stomas. sinuses. the vagina or anus should be used once and then discarded. Peripheral intact skin is prepared before open wounds and body orifices. When performing a surgical skin prep for necrotizing fasciitis: . 3. Prep the most contaminated area last using separate sponges. Perform hand hygiene prior to any contact with the patient. Sponges used to prep open wounds. Retract foreskin if prep involves the penis. 3. using principle of clean to dirty. pull foreskin back once prep is completed to prevent compromise to circulation. 4.
7.Hair Removal: 1. Clean and disinfect the reusable clipper handle after use following manufacturers’ instructions. Use a single use clipper or a clipper with a reusable handle and disposable head. 5. Stroke against the direction that the hair is growing using short strokes. 2. 4. Wash hands and don clean disposable gloves. . 3. Remove any stray clipped hair with tape or other adhesive type product to prevent contamination of the surgical site. Razor shaves are not recommended. 6. Discard disposable clipper head into an appropriate sharps container. Short hair stubble will still be evident after clipping.
under an electrosurgical dispersive electrode. Mix an appropriate amount of antiseptic scrub solution with an appropriate amount of warm sterile water in a basin.Scrub and Paint Surgical Skin Prep: 1. This allows for sudsing action of the antiseptic scrub solution. Blot cleansed area dry with a sterile towel as follows: . 6.in skin/anatomical creases. . Don sterile gloves. 5. Cleanse the skin in a linear and circular motion. between the patient and positioning devices.Lift carefully without rubbing or dragging the fabric over the cleaned area. 7. 8. Perform paint. Remove drip towels by grasping the edges in a manner to prevent the towel edges from contaminating the prepped skin. Tuck drip towels under patient as necessary to prevent pooling of solution: . Rinse cleansed area using sterile gauze moistened with sterile water. 3. and . under the patient. around a tourniquet. 2.Open a towel fully and place it over the site. or near EKG electrodes 4.
hair removal may or may not occur. Perform scrub and/or paint. 3.Head and Neck Prepsarations A. .short hair may have a thin strip of hair clipped along the incision line.Ensure prep solution penetrates through the hair to the scalp and covers all the hair and scalp in the area to be prepped. 2. . Management of hair: . 4. Scalp Prep: 1. or . Area to be prepped will vary dependent on incision site.long hair may be parted along the incision line and hair secured away from the incision with elastic bands.
9. 5. Going from medial to lateral canthus. 3. Allow to air dry. 7. Do not use Chlorhexidine or alcohol solutions. Repeat going from medial to lateral canthus. The hairline is considered a contaminated area. Using just one stroke over eyelashes. Instill a 5% povidone solution into the eye. cheek. Do not touch cornea. 4. paint operative eye. clean eyelashes of operative eye with cottontipped applicator dipped in 10% povidone iodine prep solution. 2. however DO NOT touch the mucosa or the cornea. Instill NSS into the eye. using ½ circle motions above and below eye. Ensure a cap or towel is over the patient’s head to keep hair tucked away. Eye Prep: 1. forehead and nose on correct side. 10. Do not scrub lashes. forehead and nose on correct side. Don sterile gloves. 6. paint operative eye. use chlorhexidine. . using ½ circle motions above and below eye. For patients allergic to iodine. Tuck sterile drip towels under patient as necessary to prevent pooling of solution.B. Cover the eye with a 4x4 gauze and massage eye gently especially the fornices. 11. (Note: solution of equal parts of BSS and 10% povidone iodine solution make a 5% solution) 8. cheek. Do not blot solution off of the skin.
The hairline is considered a contaminated area. 2. Do not remove eyebrows. Perform paint. and use waterproof tape if necessary to ensure hair is tucked away. Begin prep at incision site and extend to the periphery of hairline and neck. . 4. 3.C. Face Prep: 1. 5. Ensure a cap or towel is over the patient’s hair. Prep the external ear if necessary.
D. 2. . 5. Cleanse the external ear. and use waterproof tape if necessary to ensure hair is tucked away. Ear Prep: 1. Extend the prep to the edge of the hairline. face and jaw. 4. 6. Remove the absorbent cotton from the external ear canal. The hairline is considered a contaminated area. Place absorbent cotton into the external ear canal. Perform paint. 3. Ensure a cap or towel is over the patient’s hair.
Neck Prep: 1. Perform scrub. Ensure a cap or towel is over the patient’s hair and use waterproof tape if necessary to ensure hair is tucked away. The area to be prepped includes the neck laterally to the table line and up to the mandible. 3. 2.E. and chest almost to the nipple line. tops of the shoulders. .
Shoulder Prep: 1. upper arm. scapula and axilla on the affected side.Torso Preparations A. neck and shoulder. 3. 2. Prep the axilla last. Perform scrub. . Elevate the patient’s arm prior to proceeding with prep. Be careful not to pull the patient’s shoulder laterally to expose the scapular area to avoid dislocation and further injury to the patient. Area to be prepped includes the chest.
3. Chest/Breast Prep: 1. including the upper arm to elbow circumferentially and the axilla of the operative side. 7. 5. If incision is in axilla. For a breast biopsy. Prep both sides of the chest for a bilateral procedure. Skin prep for thoracic surgery requires an extension bilaterally of the boundaries for radical breast surgery. 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.B. . prep the breast from the incision area. use a separate sponge for the axilla. 2. 6. Prep the axilla last. Perform scrub. to include an area beyond the drape fenestration. 4.
Discard applicators after use. . Laparoscopic cholecystectomy). Abdominal Prep: 1. table level left to table level right (ie.C. inguinal hernia repair). Perform scrub. Area to be prepped will vary depending on surgery to be performed (ie appendectomy. Area that may be required to be included is from nipple line to upper 1/3 of thighs. Umbilicus is prepped first using sterile cotton-tipped applicators dipped in antiseptic solution. 2. 3.
Back procedure: area to be prepped includes the border of the OR table on both sides. E. Back Prep: 1. . back and mid-abdominal wall. Flank: 1. Perform scrub. Frontal prep depends on accessibility when patient is in lateral position. Perform scrub. Area to be prepped includes shoulder to iliac crest. 2. 2. Back procedure if patient is prone: area to be prepped includes from neck to sacrum.D. 3.
Do not use Chlorhexidine or alcohol solutions. Prep anus last. 5. . 3. . Vaginal Prep: 1.Prep labia majora using downward strokes. including perineum. Next: prep vaginal vault using a separate sponge mounted on a forcep. 6. 2.Use fresh sponge to prep inner thigh of second leg starting at labia majora and moving laterally using back and forth strokes.F. Place drip towel or impervious drape under buttocks to prevent prep solution from pooling under the patient’s coccyx. First: prep pelvis. Discard sponge when periphery reached. . Discard sponge when periphery reached. . 4.Use fresh sponge to prep inner thigh of first leg starting at labia majora and moving laterally using back and forth strokes. Perform scrub. labia. and thighs as follows: . perineum. Ensure towel or impervious drape is removed following completion of the preparation.Start prep at the pubis and prep to iliac crest using back and forth strokes.
2. 3 . H. 4. 2. anus and thighs. Perineal and abdominal prep shall not be performed simultaneously. Prep area surrounding anus first. prep the abdomen. labia. Perianal Prep: 1.G. The anus is prepped last being the most contaminated area. Perform scrub. Begin prep outside anal mucosa and extend outward in all directions. Next: Using a separate prep set-up. Abdominal/Perineal Prep: 1. . Prep the anus last – do not penetrate the anus itself. Perform scrub.First: Prep perineal area including pelvis. perineum. 3. 4.
4. Elevate limb for prep. . Perform scrub. 2. Place a drip sheet under the operative arm/leg prior to prep. Ensure drip sheet is removed after completion of surgical skin prep. A towel tucked around a tourniquet cuff absorbs excess solution.Extremity Skin Preparations Extremities: (General) 1. 3.
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.
4. if not part of the surgical site.Special Preparations Stomas: 1. Should a surgeon request to pack a stoma. . Seal off with a sterile adhesive drape. 2. Prep gently and last if stoma is part of the surgical incision. ensure that a radiopaque Betadine soaked sponge is used. 3. Cover the stoma with sterile clear plastic adhesive dressing to prevent fecal material from entering the surgical wound. Place a soaked sponge over the stoma before peripheral tissues are prepped and discard at completion of prep.
6. mask and eyewear). 3. 3. Irrigate wound as necessary with sterile normal saline. Use a colorless antiseptic on the donor site so that the graft vascularity may be evaluated post op. Use drip sheet under the wound. . 2. Prep surrounding intact skin. Do not use irritating solutions on denuded areas. Graft Sites 1. 4. 7. 5. 2. denuded or traumatized skin. Wear appropriate PPE (gloves. May need to cover the wound with sterile gauze while prepping surrounding areas. Use separate set-ups for recipient and donor sites. Use only normal saline to prep burned. Prep donor site first.Traumatic Wounds: 1. Position drip towels/drip sheet as appropriate.
increasing respiratory rate. Circulatory Hemorrhage – Bleeding internally or externally. Clinical signs: Rapid weak pulse. . thirst. .POST OPERATIVE COMPLICATIONS A.cause: disruption of sutures. insecure ligation of blood vessels. restlessness. pallor. reduced urine output. cold clammy skin. lowered BP. Preventive intervention: Early recognition of signs.
SOB. signs and prevention: same as thrombus.cause: venous stasis. . leg exercises. shock (tachycardia. abdomen. . Embolus – Clot that has moved from its site of formation to another area of the body. Clinical signs: Sudden chest pain. use of estrogen). antiemboli stockings. pelvis. adequate fluid intake. cyanosis.Thrombus – Blood clot attached to wall of vein or artery (most commonly the leg veins). factors causing increased blood coagulability (eg. . vein injury resulting from surgery of legs. Preventive Interventions: Early ambulation. low BP).cause.
.B. . interventions to facilitate voiding. Urinary Urinary retention – Accumulation of urine in the bladder and inability of the bladder to empty itself. bladder distention.cause: depressed bladder muscle tone from narcotics & anesthetics. handling of tissues during surgery on adjacent organs (rectum. vagina). restlessness. inability to void or frequent voiding of small amounts. suprapubic discomfort. Clinical signs: Fluid intake larger than output. Preventive Intervention: Monitoring of fluid intake and output.
urgency. early ambulation. .cause: immobilization and limited fluid intake. good perineal hygiene. early ambulation. cloudy urine. Preventive Intervention: Adequate fluid intake.Urinary tract infection – Inflammation of the bladder. Clinical signs: Burning sensation when voiding. lower abdominal pain. .
cause: lack of dietary roughage. abdominal distention. early ambulation. . high-fiber diet. Gastrointestinal Constipation – Infrequent or no stool passage for abnormal length of time (eg. . analgesics (decreased intestinal motility). Preventive Interventions: Adequate fluid intake. Clinical signs: Absence of stool elimination. within 48 hours after solid diet started). and discomfort.C.
then clear fluids.Nausea and Vomiting -cause: pain. Clinical signs: Complaints of feeling sick to the stomach. anxiety. full fluids and regular diet when peristalsis returns. certain medications. abdominal distention. . Preventive Intervention: IV fluids until peristalsis returns. retching or gagging. ingesting fluids or foods before return of peristalsis.
elevated body temp. .cause: poor aseptic technique. redness. Clinical signs: Purulent exudates. Wound Wound infection – Inflammation and infection of incision or drain site. tenderness.D. wound odor.. lab analysis of wound swab identifies causative microorganism. .
a. . either internal or external. .can be classified as open or closed. b.usually result from external physical forces.is a break in the continuity of a tissue of the body. An open wound is a break in the skin or in a mucous membrane. A closed wound involves underlying tissues without a break in the skin or a mucous membrane. .WOUND .
TYPES OF WOUNDS 1. .degree of bleeding depends on the depth and extent of a cut 3. broken glass. metal edges. Abrasions – results from scraping (abrading) the skin and thereby damaging it.bleeding may be rapid and extensive 4. Punctures – produced by bullets and pointed objects such as pins.bleeding is usually minor. or other sharp objects. 2. . . . . nails and splinters. Incisions – cuts in body tissues commonly caused by knives. . irregular or blunt breaks or tears in the soft tissues.bleeding is limited to oozing of blood from ruptured small veins and capillaries.commonly result from falls or the handling of rough objects. but the puncturing object may penetrate deeply into the body and may damage organs and soft tissues and sever internal bleeding. Lacerations – jagged.
usually followed by heavy bleeding. dead tissue.. . . heat) or by external chemicals (e. Avulsions – involve the forcible separation or tearing of tissue from the victim’s body.Third-degree wounds go deeper than the dermis and produce dry.Second-degree wounds include damage to the dermis and produce blisters. 6. Ulcers .often has destruction of tissue in a broad.First-degree burns are superficial and red. .ischemia is then created below the surface where the ulcer is seen. Burns .made by external destructive energy (e..can be made by innate destructive processes. 7. roughly circular area. . .g. acid).5. . but most ulcers are caused by external forces such as pressure.commonly caused by animal bites and accidents involving motor vehicle. guns and explosives. . friction and moisture.g. . heavy machinery. shearing.
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 .
Wet gauze dressing –retains moisture while it removes drainage from the wound.Permit air to reach the wound. 2. Hydrocolloid dressing a. Self adhesive b. b. Does not require tape d. 3. Less bulky than gauze c. Air and water occlusive dressing c. Transparent dressing a. Chief advantage is they facilitate wound assessment without removing the dressing. Non Absorbent 4. Can be left in place up to one week .Types Of Dressing 1. Dry gauze dressing .
Sterile saline or water f. when the wound requires assessment or care. and when they become loose or saturated with drainage. Waterproof bed pads c. . Supplies and equipment needed a. Irrigation pack and solution g. Plastic bag or basin e. Gather supplies and wash hands b. Tape or Montgomery straps 2. Sterile and clean gloves i.Changing of Dressing 1. Sterile dressings d. Eye shield or face guard h. Dressings are changed per doctor's orders.
Open all sterile equipment and supplies and place within the sterile field. Uncap sterile saline or other solution as ordered. . Remove gloves and dispose in plastic bag. Explain procedure to patient a. being careful not to tear the wound or dislodge any drains. i. Position the patient and expose the area to be redressed. Use sterile saline to moisten dressing if it is sticking to the wound. Put on sterile gloves. c. e. to prevent discomfort to the patient and/or to maintain integrity of sutures. Put on clean non-sterile exam gloves. odor.3. Establish a sterile field. f. Place waterproof pad under patient and prepare plastic bag as receptacle. color. Assess amount. and consistency of drainage g. Remove the dressing. h. b. Gently loosen tape toward the wound while supporting the skin around the wound or untie Montgomery straps. d.
All other dressings will overlap each other and cover entire wound 3. 6. Remove gloves and place in disposal bag CAUTION: Tape should not form a constricting band around the wound or extremity. and amount of drainage. Enter the date and time of the procedure. 8. 9.Applying a Sterile Dressing 1. 2. Lay inner dressing over wound ensuring the dressing extends past the edge of the wound. b. CAUTION: Some wounds must be kept moist. odor. and will require the use of "wet to dry" dressings. Cover all inner dressings with a large out dressing. Enter a description of the wound's color. Example: abdominal evisceration. Reposition and cover patient. 5. Document wound care and all assessments on the appropriate form a. consistency. . 7. Wash hands. Close and dispose of plastic bag with used supplies. Tape the dressing. 4. The inner dressings that touch the wound directly will be dampened with a solution (usually normal saline) before application. The outer dressings are applied dry.
wipe the wound area with an outward spiral motion. Discard the gauze. Linear wound • First stroke . • Second stroke .Continue this procedure. working away from the wound until clean. Do not use the same swab/gauze to clean the entire wound . • Third stroke . working outward until wound is clean.starting at the center of the wound.Continue this procedure alternating sides of the wound. 2. wiping from top to bottom.Cleansing the Wound 1.cleanse the skin area on one side next to the wound. Circular wound • First stroke . . Discard the gauze. Do not cross back to the center of wound. .cleanse the skin on other side of wound. Discard the gauze.cleanse the area directly over the wound by wiping from the top to bottom. wiping from top to bottom.
Irrigating the Wound 1. this step is not necessary. Irrigate all portions of the wound. Using sterile gauze. check to ensure patient does not have allergies to it. If the seal of the bottle has not been broken. Pour irrigating solution into basin with the label facing the palm 4. An alternate. non-iodine-based solution may be used (Hibiclens. . gently pat dry the edges of the wound. DO NOT force solution into wound pockets. 5. Put on sterile gloves and eye shield or face guard. 2. hydrogen peroxide). Betadine not generally used in irrigation unless severely contaminated. To prevent contamination and to clean the bottle rim. 7. Fill the syringe with solution from the sterile basin. Continue irrigating until solution draining from bottom end of wound is clear. Work from cleanest to most contaminated areas. Use enough force to flush out debris but do not squirt or splash fluid 6. Hold the tip of the syringe just above top end of wound and force fluid into the wound slowly and continuously. CAUTION: If Betadine (iodine) is being used. phisohex. if available. 3. pour a mall amount of the liquid into waste receptacle.
Different kinds of ostomies are named after their anatomic location. urinary. A person who has an ostomy uses a plastic pouch (appliance) to cover the stoma and collect the stool (effluent) or urine.OSTOMY An ostomy is an opening for the gastrointestinal. is a stoma on the outer abdominal wall for drainage of urine. or urinary diversion. large intestine to the abdominal wall) and ureterostomy. or. The most common types of ostomies in intestinal surgery are an "ileostomy" (connecting the ileal part of the small intestine to the abdominal wall) and a "colostomy" (connecting the colon. . or respiratory tract onto the skin.
Save the clamp for re-use (note that some pouches cannot be drained). 7. 3. open it by removing the clamp and unrolling it at the bottom. use the other hand to hold tension on the skin in the opposite direction of the pull. Wash hands and don clean gloves. gently remove the old wafer from the skin. places a clean towel across the patient’s abdomen under the existing pouch. If the pouch is drainable. At the same time. Position the patient so that no skin folds occur along the line of the stoma. 2. If resistance is encountered and the wafer is difficult to remove. 4. . With one hand. 8. Empty the existing ostomy pouch into a bedpan. according to facility protocol. use adhesive remover or rubbing alcohol. 6. beginning at the top and proceeding in a downward direction. Fold down the linen to expose the ostomy site.Ostomy Appliance Procedure 1. 5.
. Use a standard stoma measuring guide placed over the stoma. cuts the opening. Report excess bleeding to the physician. b. Place the old pouch and wafer in a plastic bag for disposal. 16. 17. Trace the size of the opening obtained in Step 14 onto the paper on the back of the new wafer. 13. Re-use a previously cut template.5–3 cm) larger than the circumference of the stoma. Measure the size of the stoma in one of the following ways: a. Places a clean 4×4 gauze pad over the stoma. 10. Wafer opening is approximately 1/16 to 1/8 inch (1.9. Inspect stoma and peristomal skin. Measure the stoma from side to side (approximating the circumference). dispose of it according to agency protocol. Allow the area to dry. 12. If the pouch is nondrainable. c. 14. 15. Use warm water and mild soap to cleanse stoma and surrounding skin. Remove gloves and wash hands. 11.
Remove the gauze. If using a two-piece system. applies extra adhesive paste). attaches the bag following manufacturer’s instructions.. Some resources suggest first holding the wafer between the palms of the hands to warm the adhesive ring. .18. Center the wafer opening around the stoma and gently press down. a. do not remove the backing on this tape until the wafer is securely positioned (Steps 22–24). Don clean procedure gloves. If using a one-piece pouch. If so. Peel the paper off the wafer.g. b. wipes around stoma with skin-prep. 20. 22. place the wafer on first. If ostomy skin care products are to be used. For an open-ended pouch. fold the end of the pouch over the clamp and close the clamp. applies skin barrier powder or paste. When the seal is complete. 19. c. make sure the bag is pointed toward the patient’s feet. listening for a “click” to ensure it is secure. apply them at this time (e. 21. NOTE: Some ostomy wafers come with an outer ring of tape attached.
making it adhere better. Some sources also suggest taping down the edges of the wafer. Remove gloves and wash hands. . 25. Dispose of used ostomy pouch following agency policy for biohazardous waste. 24. 26. Return patient to a comfortable position.23. Ask the patient to place her hand over the newly applied wafer to warm the adhesive ring.
color. • the periostomal skin for irritation and redness. consistency. 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. presence of blood or pus. the character of the effluent. Prior to and during the procedure. . • the patient’s knowledge and understanding of ostomy care.Nursing Responsibilities Assessment. • the feces for amount. • the stoma for swelling. the nurse should assess: • the color of the stoma.
• clamp. towel. • adhesive with brush to apply it to the bag if needed. in the form of a spray. or sheet to protect the skin. wash cloth. to protect hands. • a skin barrier. disc.Planning. • gauze pad to cover the stoma. • a water-proof bag for the soiled appliance to minimize odor. • a deodorant for a non-odorproof colostomy bag. • cleaning materials. mild soap. and in some cases. . The nurse should assemble the following equipment: • nonsterile gloves. including tissues. • scissors if the appliance does not have a precut opening. warm water. • measuring guide (stoma guidestrip) to measure the stoma.
) 9. Empty the effluent in the pouch. 5. Cleanse the periostomal skin and stoma with warm water and soap. Remove the appliance. Changing an ostomy appliance is outlined in the following procedure: 1. Dry the area thoroughly by patting with a towel. 3. 6. 2. Rationale: Excessive rubbing may abrade the skin.Intervention. Communicate acceptance and support of the patient. Explain the procedure to the patient and/or family member. where the patient can learn to care for his/her ostomy as he/she would at home. peeling the bag off slowly while holding the patient’s skin taut. 4. either sitting or lying. Provide privacy. preferably in the bathroom. . 7. 8. and expose only the stoma area. Unfasten the belt and check the method of adhesion. (Check agency policy on use of soap since soap may be irritating to the skin. Assist the patient to a comfortable position.
Discard or cleanse the bag. Measure the size of the guidestrip. The opening of the faceplate should be approximately 1/16” larger than the stoma. 13. 15. 16. Place a piece of tissue or gauze pad over the stoma. Rationale: Any seepage from the stoma will be absorbed in the tissue or gauze pad. wash hands. a spray. 14. Refer to the manufacturer’s instructions for a specific produce. Remove and discard gloves. color. Rationale: Close fit of the barrier (faceplate) prevents contact of skin with effluent. Wash soiled belt with warm water and mild soap. Document in patient’s record. • condition of stoma and peristomal skin • patient’s response • amount. 11. or liquid such as Skin Prep. and dry. Check the fit of the appliance. or a karaya product.10. Prepare and apply the skin barrier which may be in the form of a disc or sheet such as Stomahesive. rinse. and consistency of drainage . 648 12. Measure the effluent if ordered.
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 .
1. . Sterile gloves. Hemostats. 2. Supplies for prepping and dressing the wound area. Suture materials. 8. Scissors (vascular and suture). Sterile towels. 10. 4. Splint. 3. 5. if required. Equipment and supplies used in a venous cutdown are listed below. Intravenous setup. Scalpel handle and blades. 9. 6.CUT-DOWN PROCEDURE a. Other supplies and equipment as required by physician (and available). mask. 7. Equipment and Supplies.
Basilic vein above the elbow. Site. 3. Saphenous vein above the ankle.b. Some suggested sites are listed below. Basilic vein below the elbow. Cephalic vein below the elbow. 4. . Several sites may be chosen depending on the condition of the patient and the fluid to be infused. 2. 1.
. Make a transverse cut and dissect the tissue until the vein is visible (see figure 3. 4. Explain the procedure to the patient. 6. Figure 3-7. 5. gently spread the underlying tissue to fully expose the vein.7). Assemble the equipment and supplies. Apply/inject a local anesthetic so the patient will not feel the incision. Open incision for venous cutdown.c. Wash your hands. Procedure for the Cutdown. 3. Using a curved hemostat. 2. 1. Prepare and stabilize the site.
7. Figure 3-8. 8. Lift the vein and put two threads of suture under it (see figure 3-8). Leave enough vein between the two ties to insert the catheter. Thread under vein. . Tie both threads and pull in opposite directions.
(9) Nick the vein with a scalpel (or cut with vascular scissors). . Nick vein with scalpel. (See figure 3-9) Figure 3-9.
Insert catheter into vein.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.
13. 15. date and time of insertion. Apply a sterile dressing and tape the catheter in place. Attach catheter to previously prepared infusion set and close the wound. 12. Outer tape should show catheter size. 14.11. Physician will specify when to remove the skin sutures. The procedure must be documented (usually in Nursing Notes). Figure 3-11. Suture the incision and apply an antibiotic ointment (see figure 3-11). Suture incision. . and inserter's initials.
When constipated. and to drink hot liquids and fruit juices especially prune juice. . Regular exercise. beans. instruct client to increase daily fluid intake. 4. 2. the use of drinking straws and chewing gum. 6. onions and cauliflower. such as cabbage. 6. Don’t give blood. 4. Limit carbonated beverages. Don’t eliminate salt from diet. 2. Don’ts 1. 5.Colostomy Care Do’s and Don’ts Do’s 1. For diarrhea. Don’t put things into the stoma. 5. 3. Don't take any medication unless you know it will dissolve quickly and be fully absorbed. encourage oral intake of fluids and bland food. Avoid fasting. Provide privacy. Avoid eating gas-forming foods. Client should be encouraged to defecate when the urge is recognized. 3.
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