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

d. 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. asking the patient’s of his or her name when he or she is conscious. . Nurses’ Role During Surgery Pre-Operative Phase a. Verify the data with the chart. e. f. Ensure the patient’s identity is correct by checking the identity band. Obtain initial vital signs and other monitoring data essential for the success of the procedure. c. g. b. Check the orders and special procedures as well as the indication of a surgical procedure.A. Communicate with the patient’s folks in times of emergencies during the procedure as well as after the procedure. clergy or orderlies. Ensure the patient’s safety by properly checking the side rails and support while transporting in a stretcher. Alleviate the patient’s anxiety about the procedure as well as coordination with other health team members such as the doctor.

d. e.Intra-Operative Phase a. the nurse is responsible in counting the number of sponges used. Exposing only the body parts involved in the surgery. The nurse is also responsible in informing the surgeon that the instruments or sponges have been properly taken out from the procedure. He or she must make sure that side rails are up or make sure that the position of the patient is well supported all throughout the procedure. Upon closure of the operative field. . Protect the patient from falls especially during the induction of anesthesia. Properly drape the patient. Assist the surgeon during procedure which may involve handing the surgical instruments properly. The counting of sponges and instruments is done before the initial closure and after procedure. b. c. 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.

Administer medications prescribed after the surgery. a. 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.Post-Operative Phase a. Assess the vital signs of each patient for every 15 minutes for the first hour and every 30 minutes thereafter. b. . c. Teach the patient about caring for the operative site as well as advise the activities that must be done for a faster recovery.

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

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

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

Head and Neck Prepsarations A. Perform scrub and/or paint. Management of hair: . or . .hair removal may or may not occur. 3. .short hair may have a thin strip of hair clipped along the incision line. 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.Ensure prep solution penetrates through the hair to the scalp and covers all the hair and scalp in the area to be prepped. Scalp Prep: 1. 4. 2.

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

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

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

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

3. Elevate the patient’s arm prior to proceeding with prep. Perform scrub. 2. Prep the axilla last. Shoulder Prep: 1. Area to be prepped includes the chest. Be careful not to pull the patient’s shoulder laterally to expose the scapular area to avoid dislocation and further injury to the patient. neck and shoulder. scapula and axilla on the affected side. upper arm.Torso Preparations A. .

Prep the axilla last. 4. 2. to include an area beyond the drape fenestration. 3. 7. prep the breast from the incision area. .B. 6. If incision is in axilla. Perform scrub. use a separate sponge for the axilla. 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. including the upper arm to elbow circumferentially and the axilla of the operative side. 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. Chest/Breast Prep: 1. 5. For a breast biopsy.

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

D. 2. 3. . Perform scrub. Back procedure if patient is prone: area to be prepped includes from neck to sacrum. Flank: 1. Perform scrub. 2. E. back and mid-abdominal wall. Frontal prep depends on accessibility when patient is in lateral position. 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. Back Prep: 1.

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

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

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

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. Seal off with a sterile adhesive drape. Prep gently and last if stoma is part of the surgical incision. . Place a soaked sponge over the stoma before peripheral tissues are prepped and discard at completion of prep.Special Preparations Stomas: 1. ensure that a radiopaque Betadine soaked sponge is used. 2. 3. Cover the stoma with sterile clear plastic adhesive dressing to prevent fecal material from entering the surgical wound. Should a surgeon request to pack a stoma. 4.

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

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

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

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

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

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

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

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

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

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

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

The cycle can then be repeated Astringent action (coagulate protein) to remove surface debris from the wound • The compress can stick to the wound surface or there may be local pain from application or removal • Faulty technique can introduce infection .METHODS OF WOUND CLEANSING Cleansing method Compress Description Purpose Potential risks Gently pressing excess moisture from a moistened gauze/cloth applied to the wound and removing after wound contact to remove surface debris.

Irrigation Steady flow of solution across wound surface Hydrate the wound Remove deeper debris Assist with visual exam • More trauma if pressure too high • Splash back • High pressure may drive bacteria into deeper compartments Soaking Immersion of wound in solution applying an over-hydrated cloth or gauze to the wound surface (no removal of excess moisture prior to application) Hydrate the wound Allow for physical removal of debris • Disruption of moisture balance • Maceration of surrounding skin • Impaired healing with introduction of bacteria from immersion fluid .

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

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

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

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

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

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

or. is a stoma on the outer abdominal wall for drainage of urine. Different kinds of ostomies are named after their anatomic location. or respiratory tract onto the skin. 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. large intestine to the abdominal wall) and ureterostomy. or urinary diversion. urinary.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. .

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

17. Places a clean 4×4 gauze pad over the stoma. Trace the size of the opening obtained in Step 14 onto the paper on the back of the new wafer. Use warm water and mild soap to cleanse stoma and surrounding skin. 13. Remove gloves and wash hands. 14. 10. Wafer opening is approximately 1/16 to 1/8 inch (1. Report excess bleeding to the physician. cuts the opening. 11. 16. Place the old pouch and wafer in a plastic bag for disposal.5–3 cm) larger than the circumference of the stoma. 15. Measure the stoma from side to side (approximating the circumference).9. Measure the size of the stoma in one of the following ways: a. Inspect stoma and peristomal skin. If the pouch is nondrainable. c. Use a standard stoma measuring guide placed over the stoma. Allow the area to dry. 12. Re-use a previously cut template. dispose of it according to agency protocol. b. .

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

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

• the stoma for swelling. • the periostomal skin for irritation and redness. • the feces for amount. and the condition of periostomal skin from the patient’s record to compare with present findings. presence of blood or pus.Nursing Responsibilities Assessment. color. Prior to and during the procedure. . the nurse should assess: • the color of the stoma. the character of the effluent. consistency. Acquire baseline data on the size and kind of stoma. • the patient’s knowledge and understanding of ostomy care.

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

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

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

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

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

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

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

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

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

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

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