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.


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

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

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

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. a. b. Teach the patient about caring for the operative site as well as advise the activities that must be done for a faster recovery. 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. . c.

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

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

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

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

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

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

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

The area to be prepped includes the neck laterally to the table line and up to the mandible. 3. Ensure a cap or towel is over the patient’s hair and use waterproof tape if necessary to ensure hair is tucked away. .E. tops of the shoulders. 2. and chest almost to the nipple line. Perform scrub. Neck 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. . neck and shoulder. upper arm.Torso Preparations A. Shoulder Prep: 1. 3. Area to be prepped includes the chest. Perform scrub. Prep the axilla last. 2. Elevate the patient’s arm prior to proceeding with prep. scapula and axilla on the affected side.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 .

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 .

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

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

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

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

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

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. .

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

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

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