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

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

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

Post-Operative Phase a. . b. a. c. 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. Others may even warrant blood administration for those who suffered a significant amount of blood loss during the surgery. Assess the vital signs of each patient for every 15 minutes for the first hour and every 30 minutes thereafter. Monitor the patient’s vital signs and watch out for side effects of the an anesthesia such as hypothermia and disorientation.

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

Clean and disinfect the reusable clipper handle after use following manufacturers’ instructions. Wash hands and don clean disposable gloves. Stroke against the direction that the hair is growing using short strokes. Use a single use clipper or a clipper with a reusable handle and disposable head. 5. 4. 3. 6. Razor shaves are not recommended. .Hair Removal: 1. Short hair stubble will still be evident after clipping. Discard disposable clipper head into an appropriate sharps container. Remove any stray clipped hair with tape or other adhesive type product to prevent contamination of the surgical site. 7. 2.

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

short hair may have a thin strip of hair clipped along the incision line. or . 3. 4. . .long hair may be parted along the incision line and hair secured away from the incision with elastic bands. Scalp Prep: 1. Perform scrub and/or paint. Management of hair: . Area to be prepped will vary dependent on incision site. 2.Ensure prep solution penetrates through the hair to the scalp and covers all the hair and scalp in the area to be prepped.Head and Neck Prepsarations A.hair removal may or may not occur.

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

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

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

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

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

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

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

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

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

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

Elevate limb for prep. . 4. 2. 3.Extremity Skin Preparations Extremities: (General) 1. Ensure drip sheet is removed after completion of surgical skin prep. Perform scrub. A towel tucked around a tourniquet cuff absorbs excess solution. Place a drip sheet under the operative arm/leg prior to 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.

Cover the stoma with sterile clear plastic adhesive dressing to prevent fecal material from entering the surgical wound. . Seal off with a sterile adhesive drape. Place a soaked sponge over the stoma before peripheral tissues are prepped and discard at completion of prep. 3. 4. Should a surgeon request to pack a stoma. if not part of the surgical site. 2. Prep gently and last if stoma is part of the surgical incision. ensure that a radiopaque Betadine soaked sponge is used.Special Preparations Stomas: 1.

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

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

Thrombus – Blood clot attached to wall of vein or artery (most commonly the leg veins). antiemboli stockings. low BP). use of estrogen). leg exercises. shock (tachycardia. factors causing increased blood coagulability (eg. vein injury resulting from surgery of legs. pelvis. SOB. . adequate fluid intake. Embolus – Clot that has moved from its site of formation to another area of the body.cause. signs and prevention: same as thrombus. cyanosis.cause: venous stasis. abdomen. Preventive Interventions: Early ambulation. . Clinical signs: Sudden chest pain. .

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

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

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

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

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

.usually result from external physical forces.WOUND . .can be classified as open or closed. b. a. . A closed wound involves underlying tissues without a break in the skin or a mucous membrane.is a break in the continuity of a tissue of the body. either internal or external. An open wound is a break in the skin or in a mucous membrane.

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

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

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 .

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

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

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

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

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

. Hold the tip of the syringe just above top end of wound and force fluid into the wound slowly and continuously. 5. hydrogen peroxide). Put on sterile gloves and eye shield or face guard. Work from cleanest to most contaminated areas. non-iodine-based solution may be used (Hibiclens. 7. Betadine not generally used in irrigation unless severely contaminated. Pour irrigating solution into basin with the label facing the palm 4. pour a mall amount of the liquid into waste receptacle. if available. phisohex. Continue irrigating until solution draining from bottom end of wound is clear. check to ensure patient does not have allergies to it. CAUTION: If Betadine (iodine) is being used. If the seal of the bottle has not been broken. 2. Fill the syringe with solution from the sterile basin. DO NOT force solution into wound pockets. Using sterile gauze. Use enough force to flush out debris but do not squirt or splash fluid 6. gently pat dry the edges of the wound. Irrigate all portions of the wound. this step is not necessary. 3.Irrigating the Wound 1. An alternate. To prevent contamination and to clean the bottle rim.

or.OSTOMY An ostomy is an opening for the gastrointestinal. is a stoma on the outer abdominal wall for drainage of urine. 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. Different kinds of ostomies are named after their anatomic location. or urinary diversion. 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. or respiratory tract onto the skin.

4. Wash hands and don clean gloves. 8. 6. 2. beginning at the top and proceeding in a downward direction. 7.Ostomy Appliance Procedure 1. according to facility protocol. If resistance is encountered and the wafer is difficult to remove. Empty the existing ostomy pouch into a bedpan. use the other hand to hold tension on the skin in the opposite direction of the pull. . 5. gently remove the old wafer from the skin. Save the clamp for re-use (note that some pouches cannot be drained). 3. open it by removing the clamp and unrolling it at the bottom. With one hand. Fold down the linen to expose the ostomy site. At the same time. use adhesive remover or rubbing alcohol. If the pouch is drainable. Position the patient so that no skin folds occur along the line of the stoma. places a clean towel across the patient’s abdomen under the existing pouch.

Measure the size of the stoma in one of the following ways: a. b. Wafer opening is approximately 1/16 to 1/8 inch (1. 17. Use a standard stoma measuring guide placed over the stoma. Allow the area to dry. cuts the opening. 10. 12. Place the old pouch and wafer in a plastic bag for disposal. 14.9. Measure the stoma from side to side (approximating the circumference). Use warm water and mild soap to cleanse stoma and surrounding skin. If the pouch is nondrainable. Re-use a previously cut template. 16. 11. Trace the size of the opening obtained in Step 14 onto the paper on the back of the new wafer. Report excess bleeding to the physician. c. Inspect stoma and peristomal skin. Places a clean 4×4 gauze pad over the stoma. 15. . Remove gloves and wash hands. 13.5–3 cm) larger than the circumference of the stoma. dispose of it according to agency protocol.

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

Some sources also suggest taping down the edges of the wafer. . 25. Remove gloves and wash hands. Return patient to a comfortable position. making it adhere better.23. Dispose of used ostomy pouch following agency policy for biohazardous waste. Ask the patient to place her hand over the newly applied wafer to warm the adhesive ring. 26. 24.

• the feces for amount. • the patient’s knowledge and understanding of ostomy care. • the stoma for swelling. presence of blood or pus. the character of the effluent. Prior to and during the procedure. • the periostomal skin for irritation and redness. color.Nursing Responsibilities Assessment. . Acquire baseline data on the size and kind of stoma. consistency. 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.

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

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

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

Evaluation: Expected outcomes of the procedure include: • stoma of a healthy color • normal periostomal skin without signs of redness or irritation • the appliance fits snugly and allows no leakage • patient participation is at the appropriate level .

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

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

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

Tie both threads and pull in opposite directions. 8. Thread under vein. 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). Figure 3-8.7. .

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

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

14. and inserter's initials. The procedure must be documented (usually in Nursing Notes). 12. Suture incision. Outer tape should show catheter size. date and time of insertion. 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. 15. Attach catheter to previously prepared infusion set and close the wound. Figure 3-11. . 13.11.

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

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