Kozier's Peri Operative Nsg Checklist

Chapter 35 Perioperative Nursing Procedures Checklist PREOPERATIVE CARE Procedure 35-1: Teaching Moving, Leg Exercises, Deep Breathing, and Coughing Purposes Performed Preparation 1.

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Assess: • Vital signs • Discomfort • Temperature and color of feet and legs • Breath sounds • Presence of dyspnea or cough • Learning needs of the client • Anxiety level of the client • Client experience with previous surgeries and anesthesia Determine: • The type of surgery • The time of the surgery • The name of the surgeon • The preoperative orders the agency practices for preoperative care Assemble equipment and supplies: • Pillow • Teaching materials, if appropriate Check that potential distracters to teaching are not present. Include the family in the teaching, if appropriate. Procedure Explain to the client what you are going to do, why it is necessary, and how he can cooperate. Wash hands and observe other appropriate infection control procedures. Provide for client privacy.

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Show the client ways to turn in bed and to get out of bed. Instruct a client who will have a right abdominal incision or a right-sided chest incision to turn to the left side of the bed and sit up as follows: • •

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Flex the knees. Splint the wound by holding the left arm and hand or a small pillow against the incision. • Turn to the left while pushing with the right foot and grasping a partial side rail on the left side of the bed with the right hand. • Come to a sitting position on the side of the bed by using the right arm and hand to push down against the mattress and swinging the feet over the edge of the bed. Teach a client with left abdominal or left-sided chest incision to perform the same procedure but splint with the right arm and turn to the right. For clients with orthopedic surgery, use special aids, such as a trapeze, to assist with movement. Teach the client the following three leg exercises: Alternate dorsiflexion and plantar flexion of the feet. Flex and extend the knees, and press the backs of the knees into the bed while dorsiflexing the feet. Instruct clients who cannot raise their legs to do isometric exercises that contract and relax the muscles. Raise and lower the legs alternately from the surface of the bed. Flex the knee of the stable leg, and extend the knee of the moving leg. Demonstrate deep-breathing (diaphragmatic) exercises as follows: Place your hands palms down on the border of your rib cage, and inhale slowly and evenly through the nose until the greatest chest expansion is achieved Hold your breath for 2 to 3 seconds. Then exhale slowly through the mouth. Continue exhalation until maximum chest contraction has been achieved.

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Help the client perform deep-breathing exercises. Ask the client to assume a sitting position. Place the palms of your hands on the border of the client’s rib cage to assess respiratory depth. Ask the client to perform deep breathing, as described in step 6. Instruct the client to cough voluntarily after a few deep inhalations. Ask the client to inhale deeply, hold the breath for a few seconds, and then cough once or twice. Ensure that the client coughs deeply and does not just clear the throat. If the incision will be painful when the client coughs, demonstrate techniques to splint the abdomen. Show the client how to support the incision by placing the palms of the hands on either side of the incision site or directly over the incision site, holding the palm of one hand over the other. Show the client how to splint the abdomen with clasped hands and a firmly rolled pillow held against the client’s abdomen. Inform the client about the expected frequency of these exercises. Instruct the client to start the exercises as soon after surgery as possible. Encourage clients with abdominal or chest surgery to carry out deep breathing and coughing at least every 2 hours, taking a minimum of five breaths at each session. Document the teaching and all assessments.

APPLYING ANTIEMBOLI STOCKINGS Procedure 35-2: applying Antiemboli Stockings Performed Preparation 1.

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Assess both lower extremities for: • Rates, volumes, and rhythms of posterior tibial and dorsalis pedis pulses • Skin color • Skin temperature • Presence of distended veins or edema • Skin condition • Homans’ sign Determine: • Any potential or present circulatory problems • The surgeon’s orders involving the lower extremities Assemble equipment and supplies: • Tape measure • Clean antiemboli stockings of appropriate size and of the type ordered • Talcum powder or cornstarch if appropriate Take measurements as needed to obtain the appropriate-size stockings: • Measure the length of both legs from the heel to the gluteal fold (for thigh-length stockings) or from the heel to the popliteal space (for knee-length stockings). • Measure the circumference of each calf and each thigh at the widest point. • Compare the measurements to the size chart to obtain stockings of correct size. Obtain two sizes if there is a significant difference. Procedure Explain to the client what you are going to do, why it is necessary, and how she can cooperate. Wash hands and observe other appropriate infection control procedures.

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Provide for client privacy. Select an appropriate time to apply the stockings. Apply stockings in the morning, if possible, before the client arises. Assist the client who has been ambulating to lie down and elevate the legs for 15 to 30 minutes before applying the stockings. Prepare the client. Assist the client to a lying position in bed. Wash and dry her legs as needed. Dust the ankles with talcum powder or cornstarch. Apply the stockings. Reach inside the stocking from the top, and, grasping the heel, turn the upper portion of the stocking inside out so the foot portion is inside the stocking leg. Ask the client to point her toes, then position the stocking on the client’s foot. With the heel of the stocking down, and stretching each side of the stocking, ease the stocking over the toes, taking care to place the toe and heel portions of the stocking appropriately. Grasp the loose portion of the stocking at the ankle and gently pull the stocking over the leg, turning it right-side out in the process. Inspect the client’s leg and stocking, smoothing any folds or creases. Ensure that the stocking is not rolled down or bunched at the top or ankle. Remove the stockings for 30 minutes every 8 hours, inspecting the legs and skin while the stockings are off. Soiled stockings may be laundered by hand with warm water and mild soap. Hang to dry. Document: • The procedure • Assessment data • When the stockings are removed and reapplied

MANAGING GASTROINTESTINAL SUCTION Procedure 35-3: Managing Gastrointestinal Suction Performed Preparation 1.

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Assess: • Presence of abdominal distention on palpation • Auscultated bowel sounds • Abdominal discomfort • Vital signs for baseline data Determine: • Whether the suction is continuous or intermittent • The ordered suction pressure • Whether there is an order to irrigate the gastrointestinal tube, and, if so, the type of solution to use Assemble equipment and supplies: Initiating Suction • Gastrointestinal tube in place in the client • Basin • 50-mL syringe with an adapter • Stethoscope • Suction device for either continuous or intermittent suction • Connector and connecting tubing • Disposable gloves Maintaining Suction • Graduated container to measure gastric drainage • Basin of water • Cotton-tipped applicators • Ointment or lubricant • Disposable gloves Irrigation • Disposable gloves • Stethoscope • Disposable irrigating set • Sterile normal saline Procedure Explain to the client what you are going to do, why it is necessary, and how he can cooperate.

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Wash hands and observe other appropriate infection control procedures. Provide for client privacy.

Initiating Suction 4. 5.

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Position the client appropriately. Assist the client to a semi-Fowler’s position, if it is not contraindicated. Confirm that the tube is in the stomach. Put on clean gloves. Aspirate stomach contents, and check the acidity using a pH test strip. Insert air into the tube with the syringe, and listen with a stethoscope over the stomach for a swish of air. Set and check the suction. Connect the appropriate suction regulator to the wall suction outlet, and the collection device to the regulator. Check the suction level by occluding the drainage tube and observing the regulator dial during a suction cycle. If using a portable suction machine, turn on the machine and regulate the suction. Test for proper suctioning by holding the open end of the suction tube to the ear and listening for a sucking noise, or by occluding the end of the tube with a thumb. Establish gastric suction. Connect the gastrointestinal tube to the tubing from the suction by using the connector. If a Salem sump tube is in place, connect the larger lumen to the suction equipment. This doublelumen tube has a smaller tube running inside the primary suction tube. Keep the air vent tube of a Salem sump tube open and above the level of the stomach when suction is applied. After suction is applied, watch the tubing for a few minutes until the gastric contents appear to be running through the tubing into the receptacle. If the suction is not working properly, check that all connections are tight and that the tubing is not kinked. Coil and pin the tubing on the bed so that it does not loop below the suction bottle.

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Assess the drainage. Observe the amount, color, odor, and consistency of the drainage. Test the gastric drainage for pH and blood (by using Hematest) when indicated.

Maintaining Suction 9.

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Assess the client and the suction system regularly. Assess the client every 30 minutes until the system is running effectively and then every 2 hours, or as the client’s health indicates, to ensure that the suction is functioning properly. Inspect the suction system for patency of the system and tightness of the connections. Relieve blockages if present. Put on clean gloves. Check the suction equipment. To do this, disconnect the nasogastric tube from the suction over a collecting basin (to collect gastric drainage); then, with the suction on, place the end of the suction tubing in a basin of water. If water is drawn into the drainage bottle, the suction equipment is functioning properly, but the nasogastric tube is either blocked or positioned incorrectly. Reposition the client, if permitted. Rotate the nasogastric tube, and reposition it. This step is contraindicated for clients with gastric surgery. Irrigate the nasogastric tube as agency protocol states or on the order of the physician. Prevent reflux into the vent lumen of a Salem sump tube. To prevent reflux: Place the vent tubing higher than the client’s stomach. Keep the drainage collection container below the level of the client’s stomach, and do not allow it to become too full. Keep the drainage lumen free of particulate matter that may obstruct the lumen

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Ensure client comfort. Clean the client’s nostrils as needed, using the cotton-tipped applicators and water. Apply a water-soluble lubricant or ointment. Provide mouth care every 2–4 hours and as needed. Empty the drainage receptacle, according to agency policy or physician’s order. Clamp the nasogastric tube, and turn off the suction. Put on clean gloves. If the receptacle is graduated, determine the amount of drainage. Disconnect the receptacle. If the receptacle is not graduated, empty the contents into a graduated container, and measure. Inspect the drainage carefully for color, consistency, and presence of substances. Discard and replace a full receptacle, or rinse the receptacle with warm water, and reattach it to the suction. Turn on the suction and unclamp the nasogastric tube. Observe the system for several minutes to make sure function is reestablished. Go to step 17.

Irrigating a Gastrointestinal Tube 14.

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Prepare the client and the equipment. Place the moisture-resistant pad under the end of the gastrointestinal tube. Turn off the suction. Put on clean gloves. Disconnect the gastrointestinal tube from the connector. Determine that the tube is in the stomach. See step 5 above. Irrigate the tube. Draw up the ordered volume of irrigating solution in the syringe. Attach the syringe to the nasogastric tube, and slowly inject the solution. Gently aspirate the solution.

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If you encounter difficulty in withdrawing the solution, inject 20 mL of air and aspirate again, and/or reposition the client or the nasogastric tube. If aspirating difficulty continues, reattach the tube in intermittent low suction, and notify the nurse in charge or physician. After irrigating a Salem sump tube, inject 10–20 mL of air into the vent lumen while applying suction to the drainage lumen. Reestablish suction. Reconnect the nasogastric tube to suction. If a Salem sump tube is used, inject the air vent lumen with 10 mL of air after reconnecting the tube to suction. Observe the system for several minutes to make sure it is functioning. Document all relevant information. Record the time suction was started. Also record the pressure established, the color and consistency of the drainage, and nursing assessments. During maintenance, record assessments, supportive nursing measures, and data about the suction system. When irrigating the tube, record verification of tube placement; the time of the irrigation; the amount and type of irrigating solution used; the amount, color, and consistency of the returns; the patency of the system following the irrigation; and nursing assessments.

SURGICAL DRESSINGS Procedure 35-4: Cleaning a Sutured Wound and Applying a Sterile Dressing Performed Preparation 1.

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Assess: • Client allergies to wound cleaning agents • The appearance and size of the wound • The amount and character of exudates • Client complaints of discomfort • The time of the last pain medication • Signs of systemic infection Determine: • Any specific orders about the wound or dressing Assemble equipment and supplies: • Bath blanket (if necessary) • Moisture-proof bag • Mask (optional) • Acetone or another solution (if necessary to loosen adhesive) • Disposable gloves • Sterile gloves • Sterile dressing set; if none is available, gather the following sterile items: o Drape or towel o Gauze squares o Container for the cleaning solution o Cleaning solution o Two pairs of forceps o Gauze dressings and surgipads o Applicators or tongue blades, to apply ointments o Additional supplies required for the particular dressing o Tape, tie tapes, or binder

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Prepare the client and assemble the equipment. Acquire assistance for changing a dressing on a restless or confused adult. Assist the client to a comfortable position in which the wound can be readily exposed. Expose only the wound area. Make a cuff on the moisture-proof bag for disposal of the soiled dressings, and place the bag within reach. It can be taped to the bedclothes or bedside table. Put on a face mask, if required. Procedure

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Explain to the client what you are going to do, why it is necessary, and how she can cooperate. Wash hands and observe other appropriate infection control procedures. Provide for client privacy. Remove binders and tape. Remove binders, if used, and place them aside. Untie tie tapes, if used. If adhesive tape was used, remove it by holding down the skin and pulling the tape gently but firmly toward the wound. Use a solvent to loosen tape, if required. Remove and dispose of soiled dressings appropriately. Put on clean disposable gloves, and remove the outer abdominal dressing or surgipad. Lift the outer dressing so that the underside is away from the client’s face. Place the soiled dressing in the moisture-proof bag without touching the outside of the bag. Remove the under dressings, taking care not to dislodge any drains. If the gauze sticks to the drain, support the drain with one hand and remove the gauze with the other. Assess the location, type, and odor of wound drainage, and the number of gauzes saturated or the diameter of drainage collected on the dressings.

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Discard the soiled dressings in the bag as before. Remove gloves, dispose of them in the moisture-proof bag, and wash hands. Set up the sterile supplies. Open the sterile dressing set, using surgical aseptic technique. Place the sterile drape beside the wound. Open the sterile cleaning solution, and pour it over the gauze sponges in the plastic container. Put on sterile gloves. Clean the wound, if indicated. Clean the wound, using your gloved hands or forceps and gauze swabs moistened with cleaning solution. If using forceps, keep the forceps tips lower than the handles at all times. Use the cleaning methods described, or one recommended by agency protocol. Use a separate swab for each stroke, and discard each swab after use. If a drain is present, clean it next, taking care to avoid reaching across the cleaned incision. Clean the skin around the drain site by swabbing in half or full circles from around the drain site outward, using separate swabs for each wipe. Support and hold the drain erect while cleaning around it. Clean as many times as necessary to remove the drainage. Dry the surrounding skin with dry gauze swabs, as required. Do not dry the incision or wound itself. Moisture facilitates wound healing. Apply dressings to the drain site and the incision. Place a precut 4” x 4” gauze snugly around the drain, or open a 4 x 4 gauze to 4” x 8”, fold it lengthwise to 2” x 8”, and place the 2” x 8” gauze around the drain so that the ends overlap. Apply the sterile dressings one at a time over the drain and the incision. Place the bulk of the dressings over the drain area and below the drain, depending on the client’s usual position.

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Apply the final surgipad, remove gloves, and dispose of them. Secure the dressing with tape or ties. Document the procedure and all nursing assessments.