Professional Documents
Culture Documents
nd
2 Edition
SURGICAL CARE
anual of
ursing
olicies and
rocedures
Prepared by:
Nursing Policies and Procedures Committee 2011
Supervised by:
Dr. Munira Al Oseimy
General Director of Nursing-MOH
TABLE OF CONTENTS
POLICY TITLE
S.N
INDEX
NUMBER
.1
GNR-05-01
.2
GNR-05-02
.3
ANESTHESIA CLEARANCE
GNR-05-03
.4
GNR-05-04
.5
GNR-05-05
.6
GNR-05-06
.7
GNR-05-07
.8
GNR-05-08
.9
GNR-05-09
WOUND IRRIGATION
GNR-05-010
.10
.11
.12
GNR-05-011
GNR-05-012
.13
GNR-05-013
.14
GNR-05-014
.15
GNR-05-015
.16
GNR-05-016
.17
GNR-05-017
.18
GNR-05-018
DPP
TITLE:
GNR-05-001
APPLIES TO:
NURSING
NURSING ROLE IN PREOPERATIVE CARE OF
PATIENT.
APPROVAL DATE:
EFFECTIVE DATE:
NUMBER OF PAGES
1 of 5
1.0 PURPOSE
1.1 To serve as a base line data for patient information incase of emergency or referral.
1.2 To systematically patients' readiness for surgery.
2.0 DEFINITION
2.1 Pre- operative phase from the time the decision is made for surgical intervention to transference of the
patient to operating room.
2.2 Preoperative checklist- a special form to be filled up by nurses before a patient is sent for a major or invasive
procedure to ensure patients readiness for the procedure.
2.3 Old files- refers to additional files belong to the patient. Also known as additional volume.
2.4 NKA- refers to (No Known Allergy).
3.0 RESPONSIBILITIES
REGISTERD NURSE.
4.0 POLICY
4.1 Patients scheduled for surgery shall receive a pre-operative preparation for surgery prior to the
scheduled surgery time, except in emergency cases that patient cant wait even for 30 min,but still the
patient should receive pre op care even partial care.
4.2 The pre-operative check list shall be initiated by nurse transcribing the pre-operative orders.
4.3 All patients for surgery must have intravenous cannula, properly labeled with date of insertion
according to the order.
4.4 Side rails must be raised up at all times to protect patient from accident.
4.5 Routine Electro Cardio Gram (ECG) and Chest X-Ray are required for patients 40 years and above
unless specifically requested.
4.6 If the operative consent has not been signed or completed, the nurse shall notify the Most Responsible
Physician (MRP)or his design and OR, patient will be kept in the unit until the consent is completed.
4.7 Pre-Operative teaching or education shall be document.
SC-1
DPP
TITLE:
GNR-05-001
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NURSING
NURSING ROLE IN PREOPERATIVE CARE OF
PATIENT.
APPROVAL DATE:
EFFECTIVE DATE:
NUMBER OF PAGES
5.0 PROCEDURES
2 of 5
RATIONALE
SC-2
DPP
TITLE:
GNR-05-001
APPLIES TO:
NURSING
NURSING ROLE IN PREOPERATIVE CARE OF
PATIENT.
APPROVAL DATE:
EFFECTIVE DATE:
NUMBER OF PAGES
3 of 5
SC-3
DPP
TITLE:
GNR-05-001
APPLIES TO:
NURSING
NURSING ROLE IN PREOPERATIVE CARE OF
PATIENT.
APPROVAL DATE:
EFFECTIVE DATE:
NUMBER OF PAGES
4 of 5
SC-4
DPP
GNR-05-001
APPLIES TO:
NURSING
NURSING ROLE IN PREOPERATIVE CARE OF
PATIENT.
APPROVAL DATE:
EFFECTIVE DATE:
NUMBER OF PAGES
5 of 5
6.0 ATTACHMENTS
Pre operative checklist
8.0 REFERENCES
Alexander's care of patient for surgery, Mosby, 12th Edition, Unit 1, Chapter 2, Patient and Environmental
Safety, p-24-27.
NAME:
PREPARED BY:
REVIEWED BY:
APPROVED BY:
DATE
SC-5
2010
2010
2010
DPP
TITLE:
GNR-05-002
APPLIES TO:
NURSING
POST OPERATIVE CARE OF PATIENTS IN THE
WARD.
APPROVAL DATE:
EFFECTIVE DATE:
NUMBER OF PAGES
1 of 3
1.0 PURPOSE
To provide guidelines on post-operative care.
2.0 DEFINITION
Post operative phase from the time of discharge from the RR until discharge from hospital.
3.0 RESPONSIBILITIES
All Nursing Staff
4.0 POLICY
4.1 Immediate post-anesthetic care will be provided in recovery room.
4.2 The RR nurse should make immediate nursing assessment.
4.3 The RR nurse should informed the ward when the patient start to regain conscious for picking.
4.4 The ward nurse should respond immediately with out any delays.
4.5 When the ward nurse should receive complete hand over from the RR nurse.
4.6 The ward nurse should do immediate assessment to the patient before taking back to the ward.
4.7 The ward nurse should perform complete post op care until the day of discharge.
4.8 The ward nurse will closely monitor patient blood sugar if the patient is diabetic.
5.0 PROCEDURES
RATIONALE
SC-6
DPP
TITLE:
GNR-05-002
APPLIES TO:
NURSING
POST OPERATIVE CARE OF PATIENTS IN THE
WARD.
APPROVAL DATE:
EFFECTIVE DATE:
NUMBER OF PAGES
2 of 3
6.0 ATTACHMENTS
7.0 MATERIALS & EQUIPMENT
7.1 Clean linen on bed.
7.2 Disposable gloves.
7.3 Sphygmomanometer.
7.4 Stethoscope.
SC-7
DPP
TITLE:
GNR-05-002
APPLIES TO:
NURSING
POST OPERATIVE CARE OF PATIENTS IN THE
WARD.
APPROVAL DATE:
EFFECTIVE DATE:
NUMBER OF PAGES
3 of 3
8.0 REFERENCES
Alexander's care of patient for surgery, Mosby, 12th Edition, Unit 1, Chapter 2, Patient and Environmental
Safety, p-24-27.
NAME:
PREPARED BY:
REVIEWED BY:
APPROVED BY:
DATE
SC-8
2010
2010
2010
DPP
GNR-05-03
TITLE:
APPLIES TO:
NURSING
ANESTHESIA CLEARANCE
APPROVAL DATE:
EFFECTIVE DATE:
NUMBER OF PAGES:
1 of 3
1.0 PURPOSE
1.1 Guide the selection of anesthetics and other medications to be used during surgery.
1.2 Plan for the patient's postoperative recovery and pain management.
1.3 Educate the patient about the operation itself, the possible outcomes, and self-care during recovery
at home.
1.4 Determine the need for additional staff during or after surgery.
1.5 Minimize confusion caused by rescheduling operations because of last-minute discoveries about
patients' health.
1.6 Improve patient safety and quality of care by collecting data for later review and analysis.
2.0 DEFINITION
The anesthetic decision regarding the patient condition if he\she is fit for operation, usually its done pre
operatively as anesthesia evaluation refers to the series of interviews, physical examinations, and
laboratory tests that are generally done for patient which is prepared for operation.
3.0 RESPONSIBILITIES
Registered Nurse.
4.0 POLICY
4.1 Ensure for medical clearance regarding patient fitness for surgery.
4.2 All laboratory investigations, ECG and X-ray results must be available prior to assessment by the
anesthesiologist.
4.3 The nurse must assist the anesthesiologist while examining the patient.
4.4 Check for the pre-medication order written by the anesthesiologist.
4.5 The nurse must determine the patients requiring anesthesia clearance.
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ANESTHESIA CLEARANCE
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5.0 PROCEDURES
5.1 Assemble the equipment.
5.2 Identify the patient.
5.3 Explain the procedure to the patient.
5.4 Assist the anesthesiologist during the
examination.
5.5 Look at the patients file for the written
order.
5.6 Document in the nurse's note.
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RATIONALE
5.1 To maintain smooth orderly procedure.
5.2 To maintain patient safety goal.(patient
identification)
5.3 To maintain patient right and nursing ethics
practice.
5.4 To maintain nursing practice ethics.
5.5 To ensure that all written orders made by the
anesthesiologist are carried out safely.
5.6 To provide clear report about procedure steps for
continuous nursing care
6.0 ATTACHMENTS
NA
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NURSING
ANESTHESIA CLEARANCE
APPROVAL DATE:
EFFECTIVE DATE:
NUMBER OF PAGES:
3 of 3
NAME:
PREPARED BY:
REVIEWED BY:
APPROVED BY:
DATE
SC-11
2010
2010
2010
DPP
TITLE:
GNR-05-04
APPLIES TO:
NURSING
APPLICATION OF ICE CAPS, ICE PACKS(COLD
COMPRESS).
APPROVAL DATE:
EFFECTIVE DATE:
NUMBER OF PAGES
1 of 3
1.0 PURPOSE
1.1 Ice packs can be used in different cases such as:
1.1.1 To vasoconstrictor the blood vessel in the orbital region.
1.1.2 To decrease or numb sensitivity of the pain fibers in the area.
2.0 DEFINITION
NA
3.0 RESPONSIBILITIES
RIGESTERD NURSE.
4.0 POLICY
4.1 In order to carry out the procedure the nurse must insure to have a written order from the physician.
4.2 Use sterile technique when infection or ulceration is present, clean technique used for allergic
reaction.
4.3 To assess the skin every five to ten minutes for very young patient and elderly patient with circulatory
problem.
5.0 PROCEDURES
RATIONALE
SC-12
DPP
TITLE:
GNR-05-04
APPLIES TO:
NURSING
APPLICATION OF ICE CAPS, ICE PACKS(COLD
COMPRESS).
APPROVAL DATE:
EFFECTIVE DATE:
NUMBER OF PAGES
2 of 3
6.0 ATTACHMENTS
NA
8.0 REFERENCES
Fundamentals of mental nursing Mosbys 5th edition 2007.
SC-13
DPP
GNR-05-04
APPLIES TO:
NURSING
APPLICATION OF ICE CAPS, ICE PACKS(COLD
COMPRESS).
APPROVAL DATE:
EFFECTIVE DATE:
NUMBER OF PAGES
NAME:
PREPARED BY:
REVIEWED BY:
APPROVED BY:
3 of 3
DATE
SC-14
2010
2010
2010
DPP
TITLE:
GNR-05-05
APPLIES TO:
NURSING
APPROVAL DATE
EFFECTIVE DATE:
NUMBER OF PAGES
1 of 4
1.0 PURPOSE
1.1 To recognize the patient at risk to develop pressure ulcers.
1.2 To maintain skin integrity and to prevent from developing stage I decubiti.
1.3 To provide nurses with guidelines for assessing, preventing and caring of pressure ulcer and
general procedure of skin care and wound management.
2.0 DEFINITION
A pressure ulcer is defined as any lesion caused by unrelieved pressure resulting in damage of underlying
tissue between bony prominence and an external surface for a prolonged period of time.
3.0 RESPONSIBILITIES
RIGESTERD NURSE.
4.0 POLICY
4.1 Registered nurse must assess all patients for pressure ulcer risk on admission and reassessed
periodically as other condition changes.
4.2 The nurse must consider the early intervention for patient at increase risk for pressure ulcer
development.
4.3 Pressure ulcer risk assessment required a comprehensive approach including skin assessment
evaluation of factors most commonly reported to be associated with pressure ulcer development.
4.4 Pressure ulcer risk assessment must be done systemically by using (Braden Scale), patient with score
of 16 or below will be considered at risk.
4.5 Registered nurse should determine the need for implementing appropriate skin care treatment.
4.6 Turning schedule form must be used for all pressure ulcer risk patient.
Registered nurse shall
SC-15
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5.0 PROCEDURES
5.1 Review the physician order for dressing
change, medication and which product to be
used in dressing.
5.2 Identify the patient and check ID band for
correct medical record number (MRN) and
name.
5.3 Assess the patient level of comfort and
explain the procedure.
5.4 Wash hand thoroughly.
5.5 Assemble the equipment.
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RATIONALE
5.1 To maintain safety goal (patient identification).
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6.0 ATTACHMENTS
NA
SC-17
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GNR-05-05
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NURSING
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NUMBER OF PAGES
4 of 4
8.0 REFERENCES
8.1 Fundamentals of mental nursing Mosbys 5th edition 2007.
8.2 Smith duel martin photo guide of nursing skill.
NAME:
PREPARED BY:
REVIEWED BY:
APPROVED BY:
SC-18
DATE
2010
2010
2010
DPP
GNR-05-06
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NURSING
TITLE:
APPROVAL DATE:
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1.0 PURPOSE
1.1 Therapeutic bath can be use for different cases such as:
1.1.1 To replace artificially the body's sweating mechanism.
1.1.2 To reduce fever.
2.0 DEFINITION
Baths soothe, soften and reduce inflammation and relieve itching and dryness.
3.0 RESPONSIBILITIES
RIGESTRD NURSE
4.0 POLICY
4.1 Hands should be washed, although tepid sponging does not require aseptic technique, but to
prevent cross infection.
4.2 Tepid sponge bath is used for febrile patients when temperature reaches seriously elevated levels.
4.3 Chilling the patient should be avoided since it will trigger the shivering mechanism.
4.4 It is a nursing procedure and should be carried out immediately.
4.5 The patient's body temperature is assessed and recorded to evaluate the effect of tepid sponge
bath.
5.0 PROCEDURES
RATIONALE
SC-19
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NURSING
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6.0 ATTACHMENTS
8.0 REFERENCES
Smith duel martin photo guide of nursing skill
SC-20
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NURSING
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EFFECTIVE DATE:
NUMBER OF PAGES
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NAME:
PREPARED BY:
REVIEWED BY:
APPROVED BY:
DATE
SC-21
2010
2010
2010
DPP
GNR-05-07
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
NUMBER OF PAGES
1 of 2
1.0 PURPOSE
1.1 To control bleeding and provide support to the septum following surgery and nasal reconstruction .
1.2 To treat chronic nosebleeds .
2.0 DEFINITION
2.1The nasal packing is made out of synthetic open cell foam polymer of hydroxylated polyving acetal .
the surface is smooth so it can stick to the tissue and reduces bacterial growth .The nasal packs are
stitched together at the end of the nose .
3.0 RESPONSIBILITIES
3.1 Physician removes the nasal packs .
3.2 Nursing staff are responsible
3.2.1To assisted the physician to remove the packs
3.2.2 Documenting the patients status before and after procedure
3.2.3 Educating and preparing the patient for the procedure.
3.2.4 Observing complication
4.0 POLICY
4.1 Nasal packing be removed within 24-48hrs
4.2 Only physician can perform removal of nasal packs
5.0 PROCEDURES
RATIONALE
SC-22
DPP
TITLE:
GNR-05-07
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
NUMBER OF PAGES
2 of 2
6.0 ATTACHMENTS
NA
8.0 REFERENCES
8.1 Nursing Perfecting Clinical Procedureswolters kluwer / Lippincott wiliams &wilkiins
pages307-308
NAME:
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REVIEWED BY:
APPROVED BY:
DATE
SC-23
2010
2010
2010
GNR-05-08
NURSING
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1.0 PURPOSE
To promote healing process and decrease pain sensation and edema or swelling.
2.0 DEFINITION
Sitz Bath is a warm soothing water place in basin, used to aid the healing process of the perineum through
application of moist heat.
3.0 RESPONSIBILITIES
RIGESTRD NURSE
4.0 POLICY
4.1 In order to carry out the procedure the nurse must insure to have a written order from the physician.
4.2 Hot sitz bath is not a sterile procedure but it should be carried out in a clean way.
4.3 The nurse should check the temperature of the water before asking the patient to sit in order not to
create thermal injury.
5.0 PROCEDURES
RATIONALE
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5.8 Fill Sitz bath basin with warm water and place on
toilet bowl. Fill bag with warm water at temperature of
105 to 110 0 F (40 to 45 0 C and attach tubing to basin.
5.9 Hang bag overhead so a steady stream of water
will flow from the bag, through tubing, into the basin.
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7.0 ATTACHMENTS
NA
8.0
REFERENCES
Autio, L & Koozer Olsen, k ( 2002) 'The four 'S' of Wound Management, Staples, Sutures, Steristrips and
Sticky Stuff.' Holistic Nursing Practice, 16(2) 80-88. January
NAME:
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APPROVED BY:
DATE
SC-26
2010
2010
2010
DPP
TITLE:
GNR-05-09
APPLIES TO:
NURSING
APPROVAL DATE:
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NUMBER OF PAGES:
1 of 3
1.0 PURPOSE
1.1 Hot compress can be used in different cases such as:
1.1.1 To relieve pain.
1.1.2 To soften exudates for easy removal.
1.1.3 To hasten healing due to vasodilatation.
1.1.4 To localize infection.
1.1.5 To hasten suppuration.
1.1.6 To reduce congestion.
1.1.7 To reduce pressure from accumulated fluid.
1.1.8 To provide comfort.
2.0 DEFINITION
NA
3.0 RESPONSIBILITIES
RIGESTERD NURSE.
4.0 POLICY
4.1 In order to carry out the procedure the nurse must insure to have a written order from the physician.
4.2 Use sterile technique when infection or ulceration is present, clean technique used for allergic
reaction.
4.3 To assess the skin every five minutes for very young patient and elderly patient with circulatory
problem.
SC-27
DPP
TITLE:
GNR-05-09
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
NUMBER OF PAGES:
5.0 PROCEDURES
2 of 3
RATIONALE
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GNR-05-09
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NURSING
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EFFECTIVE DATE:
NUMBER OF PAGES:
3 of 3
6.0 ATTACHMENTS
NA
NAME:
PREPARED BY:
REVIEWED BY:
APPROVED BY:
DATE
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2010
2010
2010
DPP
GNR-05-10
TITLE:
APPLIES TO:
NURSING
WOUND IRRIGATION
APPROVAL DATE:
EFFECTIVE DATE:
NUMBER OF PAGES:
1 of 5
1.0 PURPOSE
1.1 Helps the wound heal properly from the inside tissue layers outward to the skin surface.
1.2 Aids to prevent premature surface healing over an abscess pocket on infected tract.
2.0 DEFINITION
Flushing the area around an open wound cleans tissues and removes cell debris and excess drainage
3.0 RESPONSIBILITIES
3.1 Physician.
3.2 Staff nurse
4.0 POLICY
4.1 Requires a physician order to perform the procedure.
4.2 Strict sterile technique must be observed.
4.3 Asses patient's condition and check for allergies, especially to antiseptic or other topical
solutions or medications.
4.4 Normal saline solution shall be used for wound irrigation, unless other solution is ordered.
4.5 After irrigations, dressing must be applied to open wounds to absorb additional purulent
drainage.
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WOUND IRRIGATION
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5.0 PROCEDURES
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5.12
5.11
To avoid contamination
when picking-up unsterile container
when sterile gloves is worn.
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5.17
5.18
5.16
5.16
To
drainage
equipment.
5.21
5.18
To
measure.
5.22
prevent
aspirating
and contaminating the
5.17
5.19
3 of 5
To prevent contamination of
clean tissue by exudates.
5.21
observe
precautionary
To allow further
drainage into the basin.
5.20
5.20
NURSING
WOUND IRRIGATION
5.17
5.19
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GNR-05-10
wound
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NURSING
WOUND IRRIGATION
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6.0 ATTACHMENTS
NON
NAME:
PREPARED BY:
REVIEWED BY:
APPROVED BY:
DATE
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2010
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GNR-05-10
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NURSING
WOUND IRRIGATION
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NURSING
MANITAINING, SHORTINING AND REMOVAL OF
WOUND DRAIN.
GNR-05-11
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NUMBER OF PAGES
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1.0 DEFINITION
DRAIN-an appliance inserted into a body cavity or wound to release air or to permit drainage. Drains
range from simple soft rubber tubes that pass from a body cavity into a dressing to wide bore tubes that
connect to a collection bag or bottle.
2.0 PURPOSE
To establish a guideline for the maintenance, shortening & removal of drain
3.0 RESPONSIBILITIES
Physician.
Staff nurse.
4.0 POLICY
4.1 A physicians order is required to remove or shorten a drain.
4.2 Any qualified nurses perform this procedure following successful completion of the competency
based check-off for Care of Drains.
4.3 The procedure must be done in sterile technique.
4.4 During removal the clamp must be released except esophagectomy patients must be clamped.
4.5 If resistance is met during drain removal, discontinue procedure and notify physician.
4.6 After drain removal the nurse should assist the wound and notify the physician for any abnormalities.
4.7 The nurse should document all in the nursing notes.
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MANITAINING, SHORTINING AND REMOVAL OF
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6.0 PROCEDURES
RATIONALE
6.2 Identify the patient and explain the procedure. Check 6.2To ensure accuracy of patient
ID band for correct medical record numbers and name.
identification.
6.3 Provide privacy, screen patient.
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6.9.1 Grasp the drain with sterile gloves and pull the drain
the specified length to be shortened. Use sterile gauze for
extra grip if drain is slippery. Use sterile gauze for extra
grip if drain is slippery.
6.9.2 Place a sterile safety pin through the drain just above 6.9.2 A safety pin prevents the drain
the skin surface.
slipping back within the wound.
from
6.9.3 Cut the excess drain that has been pulled, leaving no 6.9.3 Excess drain above the skin may lead
more that 5cm above the skin surface.
to skin breakdown due to extra moisture.
6.9.4 Place the pre-split gauze around the drain, and then
6.9.4 The gauze provides a cushion and
position the second gauze in an overlapping pattern.
absorbs secretions, protecting the skin.
Secure with tape.
6.9.5 If pre-split gauze is not available use two (2) 4 x 4
gauze squares folded lengthwise and position around the 6.9.5 Do not cut gauze as threads and lint
drain.
may enter the open wound.
6.9. 6 Document on daily Nurses Record the following:
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7.0 ATTACHMENTS
NURSING NOTE FORM.
8.0 REFERENCES
hia,PA.Timby, B.K., Lillis, C. & Grose, L.G. (1998). Clinical Nursing Procedures, 2nd Edition.
Lippincott Publisher, Philadelphia, PA.
Nettina,S.M. et. Al. 2001.The Lippincott Manual of Nursing Practice 7th Edition. Lippincott Williams
and Wilkins: Philadelp
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NURSING
NURSING ROLE IN ASSISING PHYSICIAN FOR
INCISION AND DARAINAGE OF WOUND.
GNR-05-12
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1.0 PURPOSE
1.1 Drains are placed in wounds when abnormal fluid collections are present or expected.
1.2 Collection of body fluids in wounds can be harmful in different ways such as:
1.2.1 Provides culture media for bacterial growth.
1.2.2 Causes increased pressure at surgical site, interfering with blood flow to area.
1.2.3 Causes pressure on adjacent areas.
1.2.4 Causes local tissue irritation and necrosis.
2.0 DEFINITION
The opening and facilitating of drainage from infected wounds or abscesses.
3.0 RESPONSIBILITIES
RIGESTERD NURSE.
4.0 POLICY
4.1 Physician order should be maintained before starting the procedure.
4.2 A qualified nurse should assist in the procedure.
4.3 Fragment assessment of the surgical site & accurate recording of observation is important.
5.0 PROCEDURES
RATIONALE
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GNR-05-12
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GNR-05-12
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8.0 REFERENCES
hia,PA.Timby, B.K., Lillis, C. & Grose, L.G. (1998). Clinical Nursing Procedures, 2nd Edition.
Lippincott Publisher, Philadelphia, PA.
Nettina,S.M. et. Al. 2001.The Lippincott Manual of Nursing Practice 7th Edition. Lippincott Williams
and Wilkins: Philadelp
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APPROVED BY:
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NURSING
NURSING ROLE IN ASSISING PHYSICIAN FOR
INCISION AND DARAINAGE OF WOUND.
GNR-05-12
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TITLE:
APPLIES TO:
NURSING
OSTOMY CARE SURE FIT, OSTOMY POUCH
APPLICATION, CARE, REMOVAL.
GNR-05-13
APPROVAL DATE:
EFFECTIVE DATE:
NUMBER OF PAGES
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1.0 PURPOSE
1.1 To establish procedural guidelines for the application, care, and removal of a surfit ostomy pouch
on patients with a stoma.
1.2 To protect the skin, control odor, contain output, and facilitate nursing assessment of stoma.
2.0 DEFINITION
Finding and maintaining a stoma appliance.
3.0 RESPONSIBILITIES
Register nurse.
4.0 POLICY
4.1 This procedure is performed by assigned nursing personnel and should be taught to the patient
and/or family.
4.2 Patient should be instructed to periodically inspect to avoid leakages & protect the peri-stomal
skin.
5.0 PROCEDURES
RATIONALE
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5.10.3 Edema.
5.10.4 Drainage.
5.11Flange size on the surfit wafer should
be selected at least larger in diameter
than the stoma.
stoma.
5.12.6 Tape four (4) edges of the wafer using paper tape.
5.12.7 Attach the belt if desired.
5.12.7 For added security.
5.12.8 Ensures no leakage of discharge.
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APPLICATION, CARE, REMOVAL.
GNR-05-13
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EFFECTIVE DATE:
NUMBER OF PAGES
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8.0 REFERENCES
hia,PA.Timby, B.K., Lillis, C. & Grose, L.G. (1998). Clinical Nursing Procedures, 2nd Edition.
Lippincott Publisher, Philadelphia, PA.
Nettina,S.M. et. Al. 2001.The Lippincott Manual of Nursing Practice 7th Edition. Lippincott Williams
and Wilkins: Philadelp
NAME:
PREPARED BY:
REVIEWED BY:
APPROVED BY:
DATE
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NURSING
WOUND CARE APPLICATION OF DRY AND WET TO
DRY DRESSING
GNR-05-14
APPROVAL DATE
EFFECTIVE DATE
NUMBER OF PAGES
1 of 7
1.0 PURPOSE
1.1 To prevent contamination of the wound
1.2 To prevent wound infection
1.3 To promote early healing process and recovery
2.0 DEFINITION
NA
3.0 RESPONSIBILITIES
Registered nurse.
4.0 POLICY
4.1 An aseptic technique should be implemented during wound care
4.2 The nurse should have adequate knowledge on the performance of the procedure.
4.3 Appropriate nursing assessment of wound should be instituted which include the following: colon,
site, drainage, evidence & healing and presence of neurotic tissue.
4.4 Patient level of comfort should be considered during the performance of the procedure.
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5.0 PROCEDURES
RATIONALE
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dressings.
(If dressing
organisms
in bag.
material on gloves.
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to incision or wound
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without contamination.
moist gauze.
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DRY DRESSING
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8.0 REFERENCES
Nettina,S.M. et. Al. 2001.The Lippincott Manual of Nursing Practice 7th Edition. Lippincott Williams
and Wilkins: Philadelp
NAME:
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REVIEWED BY:
APPROVED BY:
DATE
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1.0 PURPOSE
1.1 It is usually inserted during surgery in anticipation of substantial postoperative drainage.
1.2 To reduce the risk of infection and skin breakdown.
1.3 reduces the number of dressing changes.
1.4 To Promotes healing and prevents swelling by suctioning the serosanguinous fluid that
accumulates at the trauma site.
2.0 DEFINITION
A closed wound drain is a perforated tubing connected to a portable vacuum unit.
3.0 RESPONSIBILITIES
Registered nurse.
4.0 POLICY
4.1 Verify physicians order prior to handling and care of the closed wound drain.
4.2 Assess patients clinical condition, the site of the drain.
4.3 Measure and record its content each shift.
4.4 A qualified nurse must inspect the suture site that secure the drain for signs of pulling or tearing,
swelling or infection of surrounding skin.
4.5 Requires close observation of the wound drainage to maintain maximum suction and prevent
strain in the suture line.
5.0 PROCEDURES
RATIONALE
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8.0 REFERENCES
Alexander's care of patient for surgery, Mosby, 12th Edition
NAME:
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APPROVED BY:
DATE
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1.0 PURPOSE
The purpose is to outline the steps that are taken by the staff nurse to ensure sutures/staples are removed
effectively.
2.0 DEFINITION
Skin sutures or staples are usually inserted over an incised or open wound to facilitate early healing
process.
3.0 RESPONSIBILITIES
Registered nurse.
4.0 POLICY
4.1 Sutures and staples are removed only by a physician's order. Ensure orders regarding removal of
alternate or every other suture or staple are written and followed.
4.2 Running or continuous are to be removed by a physician.
4.3 Qualified nurse that has successfully completed the competency based check-off for suture and
staple removal may perform this procedure.
5.0 PROCEDURES
RATIONALE
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6.0 ATTACHMENTS
NA
8.0 REFERENCES
8.1 Autio, L & Koozer Olsen, k ( 2002) 'The four 'S' of Wound Management, Staples, Sutures, Steristrips
and Sticky Stuff.' Holistic Nursing Practice, 16(2) 80-88. January
8.2 Berman et al Kozier & Erb's techniques in Clinical Nursing 5th Edition 2002 . Upper Saddle River.
N.J. Pearson Education Inc.
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APPROVED BY:
DATE
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2010
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TITLE:
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DPP
TITLE:
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NURSING
SURGICAL SKIN PREPRATION SHAVING AND
PREPRATION FPOR OR.
GNR-05-17
APPROVAL DATE
EFFECTIVE DATE
NUMBER OF PAGES
1 of 3
1.0 PURPOSE
1.1 To reduce the microbial flora of the patients skin prior to performing an invasive procedure.
2.0 DEFINITION
2.1 Surgical skin preparation is the removal of soil and transient microorganism from the skin, usually
done to patients scheduled for operation.
3.0 RESPONSIBILITIES
3.1 RIGESTERD NURSE.
4.0 POLICY
4.1 To be performed by experienced nursing staff.
4.2 Verify the Physicians pre-operative order.
4.3 Surgical procedures, such as grafts, abdominal-perineal and abdominal-vaginal require two
separate skin preps to be performed.
4.5 The health care facility should use FDA-approved agents that have immediate, cumulative, and
persistent antimicrobial action.
5.0 PROCEDURES
RATIONALE
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ethics practice.
5.7 Tuck in paper towels or blue pad under the site to
be prepared.
5.8 Moisten the specific site with soap and water and
shave. Avoid nicking the skin. If nicking occurs
inform treating physician.
5.9 Remove hair struck on the razor, by rinsing it on
bowl of water, wipe, dry and continue shaving until
the procedure is completed.
5.10 Discard used paper towels into a plastic bag as
you proceed dispose sharp into sharp container.
5.11 Rinse off excess soap and loose hair from the
skin with clean water if non-ambulant, dries skin and
tidy environment.
If ambulatory:
Instruct client to rinse off excess soap and loose hair in the
bathroom.
Non-Ambulant Client :
Rinse off with moist gauze and inspect for total removal
of hair.
5.12 Document the procedure and patients response.
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8.0 REFERENCES
Berman et al Kozier & Erb's techniques in Clinical Nursing 5th Edition 2002 . Upper Saddle River. N.J.
Pearson Education Inc.
NAME:
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APPROVED BY:
DATE
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1.0 PURPOSE
To achieve an appropriate application of elastic bandage without complication.
2.0 DEFINITION
NA
3.0 RESPONSIBILITIES
RIGESTERD NURSE.
4.0 POLICY
4.1 A physician's order is required for application of elastic bandages.
4.2 Standard precautions are to be followed during application of bandages.
4.3 Comparison of area before and after application of bandage is necessary to ensure continued
adequate circulation. Impairment of circulation may result in coolness to touch when compared with
opposite side of body, cyanosis or pallor of skin, diminished or absent pulses, edema or localized
pooling, and numbness or tingling of part.
5.0 PROCEDURES
RATIONALE
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6.0 ATTACHMENTS
NA
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NAME:
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3 of 3
DATE
SC-67
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2010
2010