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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 .

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

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

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

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

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

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

Different kinds of ostomies are named after their anatomic location. A person who has an ostomy uses a plastic pouch (appliance) to cover the stoma and collect the stool (effluent) or urine. or urinary diversion.OSTOMY An ostomy is an opening for the gastrointestinal. is a stoma on the outer abdominal wall for drainage of urine. large intestine to the abdominal wall) and ureterostomy. or respiratory tract onto the skin. urinary. The most common types of ostomies in intestinal surgery are an "ileostomy" (connecting the ileal part of the small intestine to the abdominal wall) and a "colostomy" (connecting the colon. . or.

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

Places a clean 4×4 gauze pad over the stoma. 14. Measure the size of the stoma in one of the following ways: a. Use warm water and mild soap to cleanse stoma and surrounding skin. 16.9. Allow the area to dry.5–3 cm) larger than the circumference of the stoma. 10. Remove gloves and wash hands. 17. If the pouch is nondrainable. 11. b. 15. Wafer opening is approximately 1/16 to 1/8 inch (1. Measure the stoma from side to side (approximating the circumference). Report excess bleeding to the physician. cuts the opening. Trace the size of the opening obtained in Step 14 onto the paper on the back of the new wafer. 13. Inspect stoma and peristomal skin. c. Use a standard stoma measuring guide placed over the stoma. 12. dispose of it according to agency protocol. . Re-use a previously cut template. Place the old pouch and wafer in a plastic bag for disposal.

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

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

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

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

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

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

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

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

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

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

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

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

15. Apply a sterile dressing and tape the catheter in place. Figure 3-11. Suture the incision and apply an antibiotic ointment (see figure 3-11). date and time of insertion. and inserter's initials. Suture incision. Physician will specify when to remove the skin sutures. Attach catheter to previously prepared infusion set and close the wound. The procedure must be documented (usually in Nursing Notes). 13. 14. . 12.11. Outer tape should show catheter size.

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

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