DPP

Transcription

DPP

Ministry Of Health, General Directorate Of Nursing
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
Ministry of Health, General Nursing Administration
Functions and Duties Policies and Procedures
______________________________________________
GENERAL NURSING: SURGICAL CARE
TABLE OF CONTENTS
POLICY TITLE
S.N
INDEX
NUMBER
.1
NURSING ROLE IN PREOPERATIVE CARE OF PATIENT.
GNR-05-01
.2
POST OPERATIVE CARE OF PATIENTS IN THE WARD.
GNR-05-02
.3
ANESTHESIA CLEARANCE
GNR-05-03
.4
APPLICATION OF ICE CAPS, ICE PACKS(COLD COMPRESS).
GNR-05-04
.5
MANAGEMENT OF PRESSURE SORE
GNR-05-05
.6
TEPID SPONGE BATH
GNR-05-06
.7
NURSING IN REMOVAL OF NASAL PACK
GNR-05-07
.8
HOT SITZ BATH
GNR-05-08
.9
APPLICATION (MOIST HEAT) HOT COMPRESS.
GNR-05-09
WOUND IRRIGATION
GNR-05-010
.10
.11
.12
MANITAINING, SHORTINING AND REMOVAL OF WOUND
DRAIN
NURSING ROLE IN ASSISING PHYSICIAN FOR INCISION AND
DARAINAGE OF WOUND
GNR-05-011
GNR-05-012
.13
OSTOMY CARE SURE FIT, OSTOMY POUCH APPLICATION,
CARE, REMOVAL.
GNR-05-013
.14
WOUND CARE APPLICATION OF DRY AND WET TO DRY
DRESSING
GNR-05-014
.15
CARE OF CLOSED WOUND DRAIN
GNR-05-015
.16
STAPLE OR SUTURE REMOVAL
GNR-05-016
.17
SURGICAL SKIN PREPRATION SHAVING AND PREPRATION
FPOR OR.
GNR-05-017
.18
ELASTIC BANDEGE APPLICATION AND REMOVAL.
GNR-05-018
______________________________________________
INTERNAL POLICY AND PROCEDURE
POLICY NUMBER:
DPP
TITLE:
GNR-05-001
APPLIES TO:
NURSING
NURSING ROLE IN PREOPERATIVE CARE OF
PATIENT.
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
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
______________________________________________
POLICY NUMBER:
DPP
TITLE:
GNR-05-001
APPLIES TO:
NURSING
PATIENT.
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
5.0 PROCEDURES
2 of 5
RATIONALE
5.1 Assess the patient's and his family reaction and
concerns about the forthcoming operation with
physician's assistance. Report any concern to treating
physician.
5.2 Check operative consent if properly filled up by
surgeon:
5.2.1 Complete surgical procedure with site if
applicable.
5.2.2 Signature of surgeon who explained the
procedure.
5.1 To relive patient anxiety.
5.2Written permission is best and legally
acceptable.
5.2.1To insures that the patient
understands the nature of the treatment
including potential complication and to
insure the patient that the procedure is
performed on the correct body part.
5.2.2To indicate that the patients
decision was made without pressure.
5.2.3 Signature of patient or qualified guardian.
5.2.4 Signature of the nurse as witness that the
procedure is will explained to the patient and
that he agree and sign.
5.3 Check for consultation if required or done (i.e.
chest, cardiac, medical).
5.4 Check for patient's written history and physical
examination sheet.
5.5 Check if patient has history of allergy or no known
allergy.
5.6 Provide pre op education by instructing and
demonstrating some activities that the patient will
practice and to do post operatively such as:
diaphragmatic breathing, coughing, turning, foot and
leg exercises and early ambulation.
SC-2
5.2.4 To make sure that the patient fully
understand the procedure by doctor and
agree.
5.4 To have base line data about the
patient.
5.5 To prevent from drug allergic
reaction.
5.6 To help the patient to understand the
surgical experience, to minimize anxiety
and promote full recovery from surgery
and anesthesia and minimize post
operative complications.
______________________________________________
POLICY NUMBER:
DPP
TITLE:
GNR-05-001
APPLIES TO:
NURSING
PATIENT.
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
5.7 If Patient has history of Diabetic Mellitus (DM) to
follow DM protocol according to hospital policy and
doctor order.
5.8 Valuables (jewelries, cash, ID's passport) should
be secured according to hospital policy.
5.9 Prepare the patient for necessary diagnostic
investigations such as CBC, chemistry, serology,
blood and grouping, PT & PTT, and ECG & chest Xray report any abnormality to treating physician.
5.10 Check for presence of contact lenses, eye glasses
and artificial dentures must be removed:
5.10.1 Implants and pace maker must be
known.
5.10.2 Hairpins, make up and nail polish must
be removed.
3 of 5
5.7 To monitor glucose level in the
blood and to prevent occurrences of
hypoglycemia.
5.9 To maintain base line for patient and
to detect if patient have any
abnormalities.
5.10 Dentures to prevent from intubation
complication.
5.10.1 To do special precautions.
5.10.2 Metal jewellery or hairpins
may be lost accidentally, and may
cause damage to the patient through
burns and abrasions and ready
source for cross infection. Nail
polish can effect in checking for
patient circulation.
5.11 Prepare the patient's skin for surgery by shaving.
5.11 To prevent from wound infection.
5.12 Site marking if applicable according to the
operation.
5.13 Bowel preparation according to the type of
surgery as ordered (e.g. cathartics, enemas ect).
5.12 To insure the correct body part for
procedure performing.
5.13 To prevent danger of faecal
spillage.
5.14 To prevent aspiration during
intubation and post operative
complication.
5.15 To prepare patient for operation and
to maintain patient hygiene to minimize
the chance of infection.
5.14 Keep patient NPO for at least 8-10 hours prior to
surgery.
5.15 Ensure patient's personal hygiene: Showering or
bathing the night prior to surgery or morning of the
schedule surgery.
SC-3
______________________________________________
POLICY NUMBER:
DPP
TITLE:
GNR-05-001
APPLIES TO:
NURSING
PATIENT.
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
5.16 Assist the patient to dress in OR gown, head and
shoe cover and underwear to be removed .Ties of
gown should be at the back according to hospital
standard.
5.17 Insert IV cannula and start IV Fluid as ordered.
5.18 Re check proper identification of patient (ID
bands / bracelet, medical file / record) and fell-up preop checklist before sending to OR.
5.19 Administer pre-anesthetic medications as
prescribed by Anesthesiologist.
5.20 Advice patient to remain in bed after pre-med is
given. Make call bell available and instruct on how to
use.
5.21 Check and record VS before sending patient to
OR and report any abnormality at once to treating
Physician.
5.22 Check if any tubes or drain attached to patient.
4 of 5
5.18 To maintain patient safety
goal.(patient identification)
5.19 To maintain patient right and
nursing ethics practice.
5.20 Due to the affect of the meds and to
prevent from patient fall.
5.21 Due to stress will affect the blood
pressure and to insure homodynamic
stabilization.
5.22 To check tube potency if there is
any abnormalities.
5.23 Help to transfer patient to OR trolley safely.
5.24 To provide clear report about
procedure steps for continuous nursing
care
5.24 Complete all necessary documentation /
recording.
5.25 Re-ensure Pre-Operative Check list is complete.
5.26 Escort the patient to OR with complete medical
record, X-rays, and ensure complete and clear
handover at the OR receiving area.
5.27 Pre operative checklist must be both signed by
the ward nurse and the receiving nurse with date and
time indicated.
5.28 Hand over the case to Operation Room
nurse.
SC-4
5.26 To keep it ready if needed or
requisitioned by physician.
5.27 To ensure that the patient arrive to
OR with complete document and in
proper time for operation.
5.28 To provide the Operation Room
nurse about all patient reports.
______________________________________________
POLICY NUMBER:
TITLE:
DPP
GNR-05-001
APPLIES TO:
NURSING
PATIENT.
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
5 of 5
6.0 ATTACHMENTS
Pre operative checklist
7.0 MATERIALS & EQUIPMENT
.7.1 Pre operative checklist.
7.2 Inform consent.
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
Mss.Lina AL-Harbi -Clinical Instructor GS Unit - King Fahad HospitalJeddah
Mrs. Mrs.Ashwag O. Shibah – RN,BSN King Fahd hospital -jedsdah
Central Committee Of NPP 2010
General Directorate Of Nurs-ing- MOH.KSA
SC-5
2010
2010
2010
______________________________________________
POLICY NUMBER:
DPP
TITLE:
GNR-05-002
APPLIES TO:
NURSING
POST OPERATIVE CARE OF PATIENTS IN THE
WARD.
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
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.
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
5.1 Obtain a report from the recovery room
nurse.
5.1 To have detailed information about
the nature of the surgical intervention,
pre-operative care given and post operative
instructions.
5.2 Transfer the patient.
5.3 Assess level of consciousness.
5.4 To assess the wound for bleeding or any
abnormalities.
5.4Check the eye dressing at the operative site.
5.5 Hang IV fluid, check for the level and
patency.
SC-6
______________________________________________
POLICY NUMBER:
DPP
TITLE:
GNR-05-002
APPLIES TO:
NURSING
WARD.
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
5.6 Monitor vital signs till stable.
2 of 3
5.6 To maintain electrolyte imbalance.
5.7 To provide clear report for continuous
nursing care
5.8 To prevent from pressure on the post
operative site.
5.7 Record in chart.
5.8 Keep patient lie on back or unaffected side
5.9 Check doctors orders and follow as directed
5.10 Put up side rails till patient is in full
recovery
5.11 Check for post-op blood sugar and inform
the medical specialist if patient is diabetic.
5.12 Assess post-operative pain or signs of
nausea –medicate as ordered by the doctor.
5.13 Discontinue IV fluid when ordered and
start diet as ordered for diabetic patient should
be DM diet and make sure that diet is tolerated.
5.14 Report immediately any increase in vital
sign or significant observation to the doctor.
5.15 Do oral hygiene.
5.16 Leave call bell within reach of patient.
5.17 Observe patient frequently.
5.18 Start patient medicine as ordered.
5.19 Document in the nurse’s notes.
6.0 ATTACHMENTS
7.1 Clean linen on bed.
7.2 Disposable gloves.
7.3 Sphygmomanometer.
7.4 Stethoscope.
SC-7
5.10 To maintain safety goal (prevent falls).
5.11 To determine level of blood glucose
control post operatively.
5.12 To relieve distress.
5.14 To prevent from complication.
5.16 To maintain safety goal
5.19 To provide clear report about procedure
steps for continuous nursing care
______________________________________________
POLICY NUMBER:
DPP
TITLE:
GNR-05-002
APPLIES TO:
NURSING
WARD.
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
3 of 3
7.5 Clinical thermometer.
7.6 Watch with second hand.
7.7 IV Stand.
7.8 Call bell.
7.9 Glucometer machine.
7.10 Alcohol swab.
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
Mss.Lina AL-Harbi -Clinical Instructor GS Unit - King Fahad
Hospital-Jeddah
Mrs. Mrs.Ashwag O. Shibah – RN,BSN King Fahd hospital jedsdah
SC-8
2010
2010
2010
______________________________________________
POLICY NUMBER:
DPP
GNR-05-03
TITLE:
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
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.
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.
SC-9
______________________________________________
POLICY NUMBER:
DPP
GNR-05-03
TITLE:
APPLIES TO:
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES:
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 patient’s file for the written
order.
5.6 Document in the nurse's note.
NURSING
2 of 3
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
7.1 Sphygmomanometer .
7.2 Stethoscope.
7.3 Thermometer.
7.4 Tongue depressor.
7.5 Prescription of narcotic / controlled drug forms.
7.6 Medication sheet.
7.7 Patient’s medical record file.
7.8 Anesthesia sheet.
8.0 REFERENCES
Fundamentals of mental nursing Mosbys 5th edition 2007.
8.2 Smith duel martin photo guide of nursing skill.
SC-10
______________________________________________
POLICY NUMBER:
DPP
GNR-05-03
TITLE:
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES:
3 of 3
NAME:
PREPARED BY:
REVIEWED BY:
APPROVED BY:
DATE
SC-11
2010
2010
2010
______________________________________________
POLICY NUMBER:
DPP
TITLE:
GNR-05-04
APPLIES TO:
NURSING
APPLICATION OF ICE CAPS, ICE PACKS(COLD
COMPRESS).
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
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
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
5.1 Check physician’s order.
5.1 To maintain safety goal (patient
identification).
5.2 Identify the patient and check ID band for
correct medical record number (MRN) and
name.
identification).
5.3 To maintain patient right and provide nursing
ethics practice.
5.4 Standard precautions.
5.6 To maintain patient right and provide nursing
ethics practice.
5.3 Explain the procedure.
5.4 Wash hand thoroughly.
5.6 Provide privacy screen as needed.
SC-12
______________________________________________
POLICY NUMBER:
DPP
TITLE:
GNR-05-04
APPLIES TO:
NURSING
COMPRESS).
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
5.7 Check the site of application for cold
compresses.
2 of 3
5.7 To have initial assessment of the site before
applying.
5.8 Cover the ice cap/packs with cotton cloth
or towel.
5.9 Check the site of application after 5 to 10
minutes.
5.8 To absorb moisture from condensation.
5.9 To discontinue treatment of occurrence of
signs of intolerance like cyanosis, blanching,
mottling.
5.10 Observe patient’s response.
5.11 Remove after prescribed period of
treatment finish.
5.12 Dry the area after finish.
5.13 Dispose of materials appropriately.
5.13 To maintain nursing ethics in practice.
5.14 Document on the Daily Nurses Record.
5.14.1 Time of application.
5.14.2 Condition of the skin
5.14.3 Patient response.
steps for continuous nursing care.
6.0 ATTACHMENTS
NA
7.1 Ice cap / pack.
7.2 Cotton cloth, towel or gauze.
8.0 REFERENCES
Fundamentals of mental nursing Mosbys 5th edition 2007.
SC-13
______________________________________________
POLICY NUMBER:
TITLE:
DPP
GNR-05-04
APPLIES TO:
NURSING
COMPRESS).
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
NAME:
PREPARED BY:
REVIEWED BY:
APPROVED BY:
3 of 3
DATE
SC-14
2010
2010
2010
______________________________________________
POLICY NUMBER
DPP
TITLE:
GNR-05-05
APPLIES TO:
NURSING
APPROVAL DATE
EFFECTIVE DATE:
DUE FOR REVIEW
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.
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
______________________________________________
POLICY NUMBER
DPP
TITLE:
GNR-05-05
APPLIES TO:
APPROVAL DATE
EFFECTIVE DATE:
DUE FOR REVIEW
NUMBER OF PAGES
5.0 PROCEDURES
5.1 Review the physician order for dressing
change, medication and which product to be
used in dressing.
name.
5.3 Assess the patient level of comfort and
explain the procedure.
NURSING
2 of 4
RATIONALE
5.1 To maintain safety goal (patient identification).
5.2 To maintain safety goal (patient identification).
5.3 To maintain patient right and provide nursing ethics
practice.
5.4 To follow standard precautions
5.6 To maintain patient right and provide nursing ethics
practice.
5.7 unsterile gloves are sufficient if care is used not to
5.7 Put on clean disposable gloves.
touch the wound.
5.8 Lesson all tape and gently pull tape ends 5.8 This process is less painful and less disturbing to
toward the wound.
the healing process.
5.9 Remove old dressing gently, one layer at a 5.9 Hasty removal of dressing can cause trauma to the
time, and alert patient of potential discomfort.
delicate healed tissues.
5.10 observe character and amount of drainage
on dressing and appearance of wound.
5.11 Assess size and location of wound to be
dressed.
5.12 Observe wound for :
5.12.1 Odor, exudates.
5.12.2 Size, length, width, depth.
5.12.3 Wound bed, granulation, necrotic tissue,
epithelization maceration, undermining.
5.13 Dispose of solid dressing and gloves in
disposable bag.
5.14 Clean dressing table with disinfecting
5.14 To prevent cross contamination.
solution.
5.15 Open sterile dressing supplies
individually on dressing table.
SC-16
______________________________________________
POLICY NUMBER
DPP
GNR-05-05
TITLE:
APPLIES TO:
NURSING
APPROVAL DATE
EFFECTIVE DATE:
DUE FOR REVIEW
NUMBER OF PAGES
5.16 Wash hands again and don sterile gloves.
5.17 Gently clean the wound with normal
saline or other cleansing solution as doctor
order.
5.18 Rinse again with normal saline and dry.
5.16 Standard precautions
5.19 Apply topical agent or any product as
prescribed.
5.19 To improve wound healing process.
3 of 4
5.17 To prevent wound contamination.
5.18 To reduce the chance of cross contamination.
5.20 Cover with sterile gauze.
5.21 Secure dressing with adhesive tape.
5.22 Remove gloves and disposes of materials
appropriately.
5.23 Wash hands.
5.24 Document the procedure:
5.24.1 Record wound appearances and color.
5.24.2 Presence and characteristics of exudates
and any abnormality.
5.24.3 Tolerance of patient to procedure.
5.24.4 Write any medication or product used.
5.21To maintain wound stabilization.
5.24 To provide clear report about procedure steps for
continuous nursing care.
6.0 ATTACHMENTS
NA
7.1 Dressing Trolley.
7.2 Dressing set.
7.3 Normal saline.
7.4 Topical agent as ordered.
7.5 Cleansing solution.
7.5 Sterile gloves.
SC-17
______________________________________________
POLICY NUMBER
DPP
TITLE:
GNR-05-05
APPLIES TO:
NURSING
APPROVAL DATE
EFFECTIVE DATE:
DUE FOR REVIEW
NUMBER OF PAGES
4 of 4
7.6 Clean disposable gloves.
7.7 Sterile gauze.
7.8 Sterile green towel.
7.9 Underpad.
7.10 Tapes or bandages as needed.
7.11 Waste bin.
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
______________________________________________
POLICY NUMBER:
DPP
GNR-05-06
APPLIES TO:
NURSING
TEPID SPONGE BATH
TITLE:
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 3
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.
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
5.1 Identify the patient and check ID band for correct
medical record number (MRN) and name.
5.2 Check patient's temperature.
identification).
5.2 To guide as data base line.
5.3 To maintain patient right and provide
5.5 Assemble the equipment at patient bed side.
SC-19
______________________________________________
POLICY NUMBER:
DPP
GNR-05-06
APPLIES TO:
NURSING
TEPID SPONGE BATH
TITLE:
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
5.7 Give antipyretic as ordered prior to bath.
5.8 Place the patient in a comfortable position, remove
gown and extra linens, but keep the patient covered.
5.9 Place a cold compress to the patient's forehead, axilla
and groin, repeat as they become warm.
2 of 3
5.7 Helps to achieve more rapid fever
reduction.
5.9 Helps to accelerate cooling.
5.10 Observe patient for chills, shivering pallor, cyanosis
of lips and/or nail beds, or weak, rapid, irregular pulse.
5.10 To provide proper immediate measures
of treatment.
5.11 Notify the physician if temperature does not subside
in 30 minutes.
5.11 To carry out medical intervention as
ordered.
5.12 Check temperature after sponge bath.
5.12 To maintain accuracy.
6.0 ATTACHMENTS
7.1 Basin of tepid water.
7.2 Thermometer.
7.3 Bath towel.
7.4 Patient's gown.
7.5 Ice bag with cover.
7.6 Bed linens.
8.0 REFERENCES
Smith duel martin photo guide of nursing skill
SC-20
______________________________________________
POLICY NUMBER:
DPP
GNR-05-06
APPLIES TO:
NURSING
TEPID SPONGE BATH
TITLE:
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
3 of 3
NAME:
PREPARED BY:
REVIEWED BY:
APPROVED BY:
DATE
SC-21
2010
2010
2010
______________________________________________
POLICY NUMBER:
TITLE:
DPP
GNR-05-07
APPLIES TO:
NURSING
Nursing in Removal of Nasal Pack
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
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 .
3.1 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 patient’s 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
5.1 Check the patients name band and medical recorder
5.2 Inform and explain the procedure to the patient .
5.3 Monitor the nose for 2 hours after removal of packs
5.4 Remove , attend to the equipment appropriately
and Wash hands
5.5 Documentation
5.1 To ensure correct patient
5.2 To obtain their co operation
5.3 To maintain an accurate record
5.4 To provide cross infection
SC-22
5.5 Appropriate care can be planed and
implementation
______________________________________________
POLICY NUMBER:
DPP
TITLE:
GNR-05-07
APPLIES TO:
NURSING
Nursing in Removal of Nasal Pack
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
2 of 2
6.0 ATTACHMENTS
NA
7.1 Saline
7.2 Clean gauze
7.3 Forceps
7.4 Nasal suction
7.5 Nasal speculum
7.6 Nasal drops
7.7 Kidney basin
7.8 Stitch cutter
8.0 REFERENCES
8.1 Nursing Perfecting Clinical Procedureswolters kluwer / Lippincott wiliams &wilkiins
pages307-308
NAME:
PREPARED BY:
REVIEWED BY:
APPROVED BY:
DATE
Mrs.Amal Kaabia -Head Nurse K.F.H-J
Mrs. Mrs.Ashwag O. Shibah – RN,BSN King Fahd
hospital -jedsdah
SC-23
2010
2010
2010
______________________________________________
POLICY NUMBER:
GNR-05-08
NURSING
HOT SITZ BATH
TITLE:
DPP
APPLIES TO:
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 3
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.
RIGESTRD NURSE
4.0 POLICY
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
SC-24
identification).
identification).
provide nursing ethics practice.
5.5 To maintain smooth orderly
procedure.
______________________________________________
POLICY NUMBER:
DPP
GNR-05-08
APPLIES TO:
NURSING
HOT SITZ BATH
TITLE:
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
5.7 Assess patient’s condition; pain level and ability to
ambulate to bathroom.
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.
5.10 Instruct patient to use clamp on tubing to control
water flow. Ensure that patient have robe or blanket to
prevent chilling and instruct the patient to for
assistance if necessary.
5.11 Allow patient to sit for 20 minutes, then assist
patient with drying and applying a clean perineal pad
(avoid touching front pad).
5.12 Assist patient back to bed, noting tolerance of the
procedure.
5.13 Document tolerance of procedure, pain and
appearance of perineal area.
SC-25
2 of 3
5.7 Effects of childbirth, pain
medication, and lost sleep may make
patient light headed, fatigue or drowsy,
impairing her ability to ambulate and
tolerate sitting on toilet without support.
5.8 Warm water is soothing and results
in vasolidation to enhance healing, but
should not create thermal injury.
5.9 Flow of water in the basin
continuously replenishes warm water
and enhances cleansing and circulation
of the perineum, reducing inflammation
and enhance healing.
5.10 Adequate circulation of water
enhances comfort and healing.
5.11 Beneficial effects of heat are lost
after 20 minutes due to vasoconstriction.
Contamination of front of perineal might
results infection of healing tissue.
5.12 Use of warm water prolonged
sitting in one position may result in light
headedness upon standing.
5.13 Decrease swelling redness and
drainage and complete healing are the
goals of this procedure and to provide
clear report about procedure steps for
continuous nursing care.
______________________________________________
POLICY NUMBER:
DPP
GNR-05-08
APPLIES TO:
NURSING
HOT SITZ BATH
TITLE:
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
3 of 3
6.1 Sitz bath basin, bag and tubing.
6.2 Towels.
6.3 Perineal pad.
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:
PREPARED BY:
REVIEWED BY:
APPROVED BY:
DATE
SC-26
2010
2010
2010
______________________________________________
POLICY NUMBER:
DPP
TITLE:
GNR-05-09
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
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
RIGESTERD NURSE.
4.0 POLICY
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
______________________________________________
POLICY NUMBER:
DPP
TITLE:
GNR-05-09
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES:
5.0 PROCEDURES
2 of 3
RATIONALE
identification).
name.
identification).
5.7 To have initial assessment of the site before
applying.
5.7 Check the site of application for hot
compress.
5.8 Soak and then wring compress material in
hot tap water.
5.9 Apply compress material slowly and gently
to the skin.
5.10 Assess skin condition after 5 minutes for
increase swelling, excessive redness.
5.9 due to patient response if suddenly applied.
5.10 To prevent from any complication.
5.11 Remove the device 15-25 minutes or as
ordered/necessary.
5.12 Dry the area after finish.
5.14.1 Time of application.
5.14.2 Condition of the skin
5.14.3 Patient response.
SC-28
______________________________________________
POLICY NUMBER:
DPP
GNR-05-09
TITLE:
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES:
3 of 3
6.0 ATTACHMENTS
NA
7.1 Compress material (Gauze 4x4).
7.2 Clean towel.
7.3 Hot tap water.
8.0 REFERENCES
Smith duel martin photo guide of nursing skill
NAME:
PREPARED BY:
REVIEWED BY:
APPROVED BY:
DATE
SC-29
2010
2010
2010
______________________________________________
POLICY NUMBER:
DPP
GNR-05-10
TITLE:
APPLIES TO:
NURSING
WOUND IRRIGATION
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
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
3.1 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.
SC-30
______________________________________________
POLICY NUMBER:
DPP
APPLIES TO:
GNR-05-10
TITLE:
NURSING
WOUND IRRIGATION
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES:
5.0 PROCEDURES
2 of 5
RATIONALE
5.3 Explain the procedure and obtain consent.
5.7 Place the Lenin-saver pad under the patient.
identification).
identification).
procedure.
5.7 To catch any spells and avoid linen
changes.
5.8 To keep irrigating solutions flows
into it from the wound.
5.8 Place the emeses basin below the wound.
5.9 Put on non sterile gloves.
5.10 Remove the soiled dressing and discard it along
with gloves in a plastic trash bag.
5.11
5.12
Pour the prescribed amount of irrigating
solution into a sterile container.
5.11
To avoid contamination
when picking-up unsterile container
when sterile gloves is worn.
Put on sterile gloves.
5. 13 Fill the syringe with the irrigating solution then
connect the soft rubber catheter to the syringe.
5.14 Gently insert the catheter into the wound until
there is resistance.
SC-31
5. 13 A soft rubber catheter minimizes
tissue trauma, irritation and bleeding.
5.14
Prevent tissue damage or in
an abdominal wound intestinal
perforation.
______________________________________________
POLICY NUMBER:
DPP
5.15
TITLE:
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES:
Instill a slow, steady steam of irrigating
solution into the wound until the syringe empties.
Make sure the solutions places away from the
wound.
Pinch the catheter closed as your withdraw
the syringe.
5.17
Refill the syringe, reconnect it to the
catheter, and repeat the irrigation.
5.18
Remove and discard the catheter and
syringe in the plastic trash bag.
5.16
5.16
To
drainage
equipment.
5.21
Continuous wound irrigation
is needed until the prescribed
amount of solution is clear.
5.18
To
measure.
5.22
Clean the area around the wound.
Dress the wound, if ordered and apply and
sterile dressing.
prevent
aspirating
and contaminating the
5.17
5.19
Keep the patient positioned.
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
APPLIES TO:
GNR-05-10
wound
To promote local circulation
and help prevent skin breakdown
or infection.
To prevent wound infection.
Remove and discard gloves, properly
dispose of drainage solutions, sailed equipments 5.22 To observe precautionary measures.
and supplies
care.
5.23 Document on the Daily Nurses Record
SC-32
______________________________________________
POLICY NUMBER:
DPP
GNR-05-10
TITLE:
APPLIES TO:
NURSING
WOUND IRRIGATION
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES:
4 of 5
6.0 ATTACHMENTS
NON
7.1 Prescribed irrigating solution.
7.2 Sterile gloves
7.3 Soft rubber catheter.
7.4 Syringe
7.5 Kidney basin
7.6 Sterile gauze
7.7 Plastic tract bag
7.8 Linen saver pad
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:
PREPARED BY:
REVIEWED BY:
APPROVED BY:
DATE
SC-33
2010
2010
2010
______________________________________________
POLICY NUMBER:
DPP
GNR-05-10
TITLE:
APPLIES TO:
NURSING
WOUND IRRIGATION
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES:
SC-34
5 of 5
______________________________________________
POLICY NUMBER:
DPP
TITLE:
APPLIES TO:
NURSING
MANITAINING, SHORTINING AND REMOVAL OF
WOUND DRAIN.
GNR-05-11
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 5
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
Physician.
Staff nurse.
4.0 POLICY
4.1 A physician’s 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.
5.1Removal of Drain
5.1.1 Sterile suture removal set
5.1.2 Gloves for removal
5.1.3 Sterile saline for cleansing
5.14 Silk tape
5.1.5 Incontinent pad
5.1.6 Sterile dressing as needed
5.1.7 Tape Measure
5.2 Shortening of Drain
SC-35
______________________________________________
POLICY NUMBER:
DPP
TITLE:
APPLIES TO:
NURSING
WOUND DRAIN.
GNR-05-11
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
2 of 5
5.2.1 Sterile safety pin
5.2.2 Sterile suture removal set
5.2.3 Sterile dressing tray
5.2.4 Gloves (sterile) for shortening
5.2.5 Sterile saline for cleansing
5.2.6 2 - 4X4 pre split gauze (ie. tracheostomy or drain)
5.2.7 Silk tape
5.2.8 Sterile dressing as needed
5.2.9 Swabs 2 X 2
5.2.10 Incontinent pad
6.0 PROCEDURES
RATIONALE
6.1 Gather equipment.
6.1 To ensure a smooth orderly procedure.
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.
6.3 Ensures privacy.
6.4 Wash hands.
6.5 Remove soiled dressing and discard used non- sterile
gloves.
6.6 Wash hands and assemble equipment.
6.7 Put on sterile gloves.
6.8 Cleanse in a circular motion with sterile saline from
the center outward. Use a new swab for each circular
6.8 Reduce risk of contamination.
wipe.
6.9. Shortening a drain:
SC-36
______________________________________________
POLICY NUMBER:
TITLE:
DPP
APPLIES TO:
NURSING
WOUND DRAIN.
GNR-05-11
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
3 of 5
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 Nurse’s Record the following:


Condition of the site
Drainage amount, color, and odor

Amount drain was shortened

Patient tolerance to procedure.
6.9.3 Drain Removal:
6.9.3.1 Follow steps 6.1-6.8 as above.
6.9.3.2 Refer to policy & procedure for staple or suture
removal. Position blue pad under drain and area to be
SC-37
______________________________________________
POLICY NUMBER:
TITLE:
DPP
APPLIES TO:
NURSING
WOUND DRAIN.
GNR-05-11
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
4 of 5
removed. Take care not to contaminate wound
6.9.3.3 Release suction on Jackson-Pratt and Hemovac 6.9.3.3 Unreleased suction may cause tissue
drains.
trauma.
6.9.3.4 Using non-sterile gloves, grasp the drain and exert
6.9.3.4 The drain is compressed and
gentle traction to pull the drain from the wound. Ask
folded beneath the skin. Puling with force
patient to breathe in and out slowly while drain is being
may injure tissue.
removed to promote relaxation.
6.9.3.5 Place drain into blue pad before discarding.
6.9.3.6 Wash hands and don sterile gloves.
6.9.3.7 Cleanse drain site with sterile saline.
6.9.3.8 Apply a dry, sterile dressing.
6.9.3.9 Document on Nurses notes.




Date and time.
Amount and type of drainage on
removal (e.g. color, odor).
Condition of drain site.
Patient’s tolerance to procedure.
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
SC-38
______________________________________________
POLICY NUMBER:
DPP
TITLE:
APPLIES TO:
NURSING
WOUND DRAIN.
GNR-05-11
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
NAME:
PREPARED BY:
REVIEWED BY:
APPROVED BY:
5 of 5
DATE
SC-39
2010
2010
2010
______________________________________________
POLICY NUMBER
DPP
TITLE:
APPLIES TO:
NURSING
NURSING ROLE IN ASSISING PHYSICIAN FOR
INCISION AND DARAINAGE OF WOUND.
GNR-05-12
APPROVAL DATE
EFFECTIVE DATE:
DUE FOR REVIEW
NUMBER OF PAGES:
1 of 4
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.
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
SC-40
identification).
identification).
procedure.
______________________________________________
POLICY NUMBER
DPP
TITLE:
APPLIES TO:
NURSING
GNR-05-12
APPROVAL DATE
EFFECTIVE DATE:
DUE FOR REVIEW
NUMBER OF PAGES:
5.7 Cleanse site with povidone iodine.
5.8 Drape the operative site with fenestrated drape.
5.9 prepare for anesthesia according to order.
5.10 Incise the operative are with scalpel blade to
drain the wound or abscess. (Physician)
2 of 4
5.7 To disinfect the site.
5.8 Prepare for procedure.
5.9 To reduce pain.
5.11 To maintain nursing ethics in
practice
5.12 Document on the Daily Nurses Record
care.
6.0 ATTACHMENTS
Non
7.1 Ethyl chloride or cetacain spray.
7.2 Xylocaine 1%.
7.3 3cc syringe.
7.4 18 gauge needle.
7.5 25 gauge needle.
7.6 Povidone iodine.
7.7Suture set, sterile.
7.8 4 x 4 sponge, sterile.
7.9 Culturette.
7.10 Fenestrated drape, sterile.
SC-41
______________________________________________
POLICY NUMBER
DPP
TITLE:
APPLIES TO:
NURSING
GNR-05-12
APPROVAL DATE
EFFECTIVE DATE:
DUE FOR REVIEW
NUMBER OF PAGES:
3 of 4
7.11 Disposable scalpel.
7.12 Gloves, sterile.
7.13 Nu gauze.
7.14Tape
7.15Microbiology from
7.16Plastic bag
7.17Penrose drain
7.18Pen, black
7.19Gown
7.20Goggles (optional)
8.0 REFERENCES
NAME:
PREPARED BY:
REVIEWED BY:
APPROVED BY:
DATE
SC-42
2010
2010
2010
______________________________________________
POLICY NUMBER
DPP
TITLE:
APPLIES TO:
NURSING
GNR-05-12
APPROVAL DATE
EFFECTIVE DATE:
DUE FOR REVIEW
NUMBER OF PAGES:
SC-43
4 of 4
______________________________________________
POLICY NUMBER:
DPP
TITLE:
APPLIES TO:
NURSING
OSTOMY CARE SURE FIT, OSTOMY POUCH
APPLICATION, CARE, REMOVAL.
GNR-05-13
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW
NUMBER OF PAGES
1 of 4
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.
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
identification).
identification).
5.7 Place pouch vertical to the patient when
emptying.
5.7 Empty pouch into kidney basin.
SC-44
______________________________________________
POLICY NUMBER:
DPP
APPLIES TO:
NURSING
GNR-05-13
TITLE:
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW
NUMBER OF PAGES
5.8 Remove pouch from top of water, pushing skin away
from stoma adhesive and tape.
5.9 Wash peristomal skin gently with warm water and pat
dry.
2 of 4
5.8 Prevent skin trauma.
5.9 Maintain peristomal skin integrity and
promote adhesion of new pouch.
5.10 Assess the following:
5.10.1 Color.
5.10.2 Size.
5.10 Assess stoma and peristomal area.
5.10.3 Edema.
5.10.4 Drainage.
5.11Flange size on the surfit wafer should
be selected at least ¼’’ larger in diameter
than the stoma.
5.11 Measure stoma with measuring guide.
5.12 Follow procedure for stoma pouch application:
5.12.1 Trace stoma pattern on the paper covering the
stomahesive wafer.
5.12.2 Cut opening in the wafer using scissors.
5.12.3 Snap pouch onto wafer.
5.12.4 Peel off paper backing from the stomahesive wafer.
5.12.5 Place adhesive wafer gently in position around the
5.12.4Pouch clicks when in secured
position.
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.
5.12.8 Attach the closure clamp.
5.13 Empty pouch when approximately 1/3 full:
5.13.1 Open pouch, empty into bedpan/kidney basin.
5.13.2 Clean/rinse end of pouch with tap water and
washcloth.
5.13.3 Dry bottom of pouch.
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5.13.4 Add pouch deodorant.
3 of 4
5.13.4 Controls odor. Instruct patient to
avoid odor producing foods, i.e. fish, egg,
oinionn, and asparagus.
5.14 Release flatus:
5.14.1Open end of pouch.
5.14.2Gently applies pressure to pouch.
5.14.3Close pouch with a clamp.
5.15 Dispose of used equipment appropriately.
5.16 Document on the patient's medical record or Nurse's
Note's.
5.16.1 Date and time.
5.16.2 Assessment of stoma and peristomal skin.
5.16.3 Characteristics of output.
5.16.4 Patient teaching, patient family involvement.
6.0 ATTACHMENTS
NA
7.1 3 size surfit ostomy pouch
7.2 3 size surfit ostomy flexible wafer
7.3 Stoma measuring guide
7.4 Pouch clamp
7.5 Tap water
7.6 Kleenex or toilet paper
7.7 Scissors
7.8 Kidney basin or bedpan
7.9 Tape (paper
7.10 Pouch beodorant
SC-46
5.14.1To prevents leakage, never make
pinhole in a pouch to release gas.
5.15 To observe precautionary measure.
5.16To provide clear report about procedure
steps for continuous nursing care and to
ensure patient awareness' and willing to take
care at home.
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POLICY NUMBER:
DPP
TITLE:
APPLIES TO:
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4 of 4
8.0 REFERENCES
NAME:
PREPARED BY:
REVIEWED BY:
APPROVED BY:
DATE
SC-47
2010
2010
2010
______________________________________________
POLICY NUMBER:
DPP
TITLE:
APPLIES TO:
NURSING
WOUND CARE APPLICATION OF DRY AND WET TO
DRY DRESSING
GNR-05-14
APPROVAL DATE
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NUMBER OF PAGES
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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
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
identification).
identification).
5.7 Assess size and location of wound to be dressed.
5.8 Assist nurse to plan for proper type and
5.8 Assess size and location of wound to be dressed.
amount of supplies needed. Alerts nurse
when assistance is needed to hold dressings
in place.
5.9 Removal dry dressing can be painful;
5.9 Assess patient level of comfort.
patient may require pain medication.
5.10 Indicates type of dressing or
application to use.
5.10 Review medical records for dressing change
procedure.
5.11 Explain procedure to patient and instruct patient not
to touch wound area or sterile supplies.
5.12 Close room or cubicle curtains; close open windows.
SC-49
5.11 Decrease anxiety. Sudden unexpected
movement by patient could result in
contamination of wound and supplies.
5.12 Provide privacy and reduces airborne
microorganisms.
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5.13 Position patient comfortably and drape with bath
blanket to expose only wound site.
5.13 Draping provide access to wound and
minimizes unnecessary exposure.
5.14 Place disposable bag within reach of work area. Fold
5.14 Ensure easy disposal of soiled
top of bag to make cuff.
dressings.
5.15 Apply face mask (usually required when wound has
drainage that may splash into eyes of nurse) and wash
hands thoroughly.
5.15 Reduces transmission of pathogens to
exposed tissues.
5.16 Put on clean disposable gloves and remove tape,
bandage, or ties.
5.16 Prevents transmission of infectious
5.17 Remove tape, pulling parallel to skin and toward
5.17 Pulling tape toward reduces stress on
dressing. Remove remaining adhesive from skin.
suture line or wound edges.
5.18 With gloved hand, carefully remove gauze dressings,
taking care not to dislodge drains or tubes. Keep soiled
undersurface away from patient's sight.
(If dressing
sticks on wet-to-dry dressing, do not moisten it; instead
gently free dressing and warn patient of discomfort).
5.19Observe character and amount of drainage on
dressing and appearance of wound.
organisms
5.18 Appearance of drainage may be
upsetting to (wet-to-dry dressing should
debride wound).
5.19Provides estimate of drainage amount
and assessment of wounds condition.
5.20 Dispose of soiled dressings in disposable bag.
5.20 Reduces transmission of
microorganism.
5.21 Remove gloves by pulling them inside out. Dispose
5.21 Prevents contact of your hands with
in bag.
material on gloves.
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5.22 Open sterile dressing tray or individually wrapped
sterile supplies. Place on bedside table.
4 of 7
5.22 Sterile dressings remain sterile while
on or within sterile surface. Preparation of
supplies prevents break in technique during
dressing change
5.23 Apply dry dressing.
5.24 Open bottle of antiseptic solution and pour into
sterile basin.
5.25 Apply sterile gloves.
5.26 Inspect wound for appearance, drainage, & integrity.
Avoid contact with contaminated material.
5.27 Cleanse wound with antiseptic solution
5.24Open bottle of antiseptic solution and
pour into sterile basin.
5.25 Allows handling of sterile supplies.
5.26 Indicates status of healing.
5.28 Use separate swab for each cleaning stroke.
5.28 Prevents contaminating previously
cleaned area.
5.29 Clean from least contaminated area to most
contaminate.
5.29 Prevents introduction of organism into
wound.
5.30 Use dry gauze to swab in same manner to dry wound.
5.30 Reduces excess moisture, which could
eventually harbor microorganisms.
5.31 Apply antiseptic ointment if ordered, using same
technique as for cleansing.
5.32 Apply dry sterile dressings
site.
5.31 Reduces growth of microorganisms.
Ointment may be applied to dressing if
direct application causes discomfort.
to incision or wound
5.33 Apply loose woven gauze as contact layer.
5.33 Promotes proper absorption of
drainage.
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5.34 Cut 4 x 4 gauze, flat to fit around drain, if present.
Precut gauze is also available.
5 of 7
5.34 Secures drain & promotes drainage
absorption at site.
5.35 Ensures proper coverage and optional
absorption.
5.36 Protects wound from external
environment.
5.35 Apply second layer of gauze.
5.36 Apply thicker woven pad.
5.37 Apply wet to dry dressing
5.38 Pour prescribed solution into sterile basin & add fine
mesh gauze.
5.38 Contact layer must be totally moistened
to increase dressing's absorptive abilities.
5.39 Allows handling of sterile supplies
5.39 Apply sterile gloves.
without contamination.
5.40 Inspect wound for color character of drainage, type
of sutures, and drains.
5.41 Cleanse wound prescribed antiseptic solution or
normal saline. Clean from least to most contaminated
area.
5.40 Provides assessment of wound healing.
5.41 Assists in debridement & cleanses
wound of debris.
5.42 Apply moist, fine –mesh, gauze directly onto wound
surface. If wound is deep, gently pack gauze into wound
5.42 Moist gauze absorbs drainage &
adheres to debris. Wound should be loosely
with forceps until all wound surface are in contact with
packed to facilitate wicking of drainage into
moist gauze.
absorbent outer layer of dressing.
5.43Apply dry sterile, 4 x 4 gauze over wet gauze.
5.44 Cover with ABD pad surgical pad, or gauze.
5.45 Apply tape over dressing, kling roll (for
circumferential dressings) or Montgomery ties. (If
available).
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5.43 Pulls moisture from wound.
5.44Protects wound from wound.
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5.46 Expose adhesive surface of tape on end of each tie.
6 of 7
5.46 Allows frequent dressing changes
without removal of adhesive tape.
5.47 Place ties on opposite side of dressing.
5.48 Place adhesive directly on patient's skin or use skin
barrier.
5.49 Secure dressing by lacing ties across it or using
safety pins and rubber bands.
5.49 Ensures dressing remains intact and
covers wound.
5.50 Remove gloves & dispose in bag.
5.50 Reduce transmission of infection.
5.51 Assist patient to comfortable position.
5.51 Promotes well being.
5.52 Dispose of all supplies and wash hands.
5.52 Clean environment enhances comfort.
Reduces transmission of infection.
5.53 Reassess patient to determine response to dressing
change.
5.53 Determines clients comport level.
5.54 Monitor status of dressing at least every shift.
5.55 Record appearance of wound & drainage, patient's
tolerance & type of dressing applied in nurse's notes.
5.56 Record frequency of dressing change & supplies
needed on Kardex.
6.0 ATTACHMENTS
NA
SC-53
5.54 Evaluates extent of drainage &
integrity of dressing.
5.55 Documents process of wound healing
& promotes continuity in dressing change
technique.
5.56 Alerts staff members to dressing
change times & supplies needed.
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7 of 7
6.1 Sterile gloves
6.2 Dressing set ( sterile ) scissors, forceps
6.3 Sterile drape ( optional )
6.4 Gauze dressings and pads
6.5 Fine mesh gauze ( wet-to-dry only )
6.6 Sterile basin
6.7Antiseptic ointment ( optional for dry dressing )
6.8 Cleansing solution
6.9 Sterile solution ( wet-to-dry only )
6.10 Clean disposable gloves
6.11 Tape, ties or bandages as needed.
6.12 Waterproof bag
6.13 Extra gauze dressings
6.14 Bath blanket
6.15 Adhesive remover ( optional )
6.16 Disposable mask
8.0 REFERENCES
NAME:
PREPARED BY:
REVIEWED BY:
APPROVED BY:
DATE
SC-54
2010
2010
2010
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POLICY NUMBER:
GNR-05-15
TITLE:
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1 of 3
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.
Registered nurse.
4.0 POLICY
4.1 Verify physicians order prior to handling and care of the closed wound drain.
4.2 Assess patient’s 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
identification).
identification).
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5.7 Unclip the vacuum unit from patient's bed or gown.
5.7 For easy disposal of drainage.
5.8 The container expands completely as it
5.8 Release the vacuum by removing the spout plug on the
draws In air.
collection chamber.
5.7 Empty the units content into a graduated container.
5.10 Wipe the units spout and plug using a separate sterile
alcohol sponge for the spout and plug.
5.11 Fully compress the vacuum unit with one hand and
replace the spout plug with your other hand.
5.12 Check equipment patency.
5.13 Secure the vacuum unit not to apply tension to
drainage tubing when fastening It.
5.14 Fasten the vacuum unit below level of the bed.
5.15 Gently clean the sutures with sterile gauze sponges
soaked from the patients in an antiseptic skin cleanser or
pre packaged antiseptic swab.
5.16 Properly dispose of drainage solution and plastic
trash bag and clean or dispose of soiled equipment and
supplies.
5.17 Document in the nurses notes:
5.17.1 Amount and appearance of drainage.
5.17.2 Condition of suture line.
6.0 ATTACHMENTS
NA
SC-56
5.9 To measure the amount of drainage and
appearance.
5.10 Maintain aseptic technique.
5.11 To reestablish the vacuum that creates
the drains suction power
5.12 Ensure tubing is free of twist, kinks and
leaks because the drainage system must be
airtight to work properly.
5.13 To prevent possible dislodgment.
5.14 To promote drainage.
5.15 To prevent infection skin where the
suture site of the drain is secured.
5.16 Observe precautionary measures.
5.17 Indicate wound healing and no signs of
infections and to provide clear report about
procedure steps for continuous nursing care
______________________________________________
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7.1 Gloves
7.2 Graduated container
7.3 Alcohol swabs
7.4 Antiseptic solution or pre packaged antiseptic swab.
7.5 Sterile gauze swabs or sponges
7.6 Plastic trash bag.
8.0 REFERENCES
Alexander's care of patient for surgery, Mosby, 12th Edition
NAME:
PREPARED BY:
REVIEWED BY:
APPROVED BY:
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2010
2010
2010
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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.
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
5.3 Explain the procedure to the patient.
5.5 Place the patient in a comfortable position and expose
the wound utilizing non-sterile gloves.
5.6 Wash hands.
identification).
identification).
5.6 To prevent wound infection.
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5.7 Open sterile suture removal or skin staple removal kit
and assemble supplies.
5.8 Put on gloves.
5.9 Cleanse the suture line with sterile normal saline.
5.8 Maintain wound surface from
contamination.
5.9 To prevent pulling exposed suture
material through subcutaneous tissue.
5.10 Suture Removal
5.10.1 Grasp the knotted end of the suture with the sterile
forceps.
5.10.2 Pull and elevate the knot to insert the point of the
scissors.
5.10.3 Cut the suture just below the knot, while firmly
holding knot. Remove by pulling on the knotted end.
5.11 Staple Removal
5.11.1 Insert bottom hook of staple remover device under
the center of the staple.
5.11.2 Squeeze handle completely closed.
5.11.3 Hold handle closed until staple remover is away
from incision.
5.11.4 Gently pull staple from skin.
5.11.5 Repeat the steps for remaining staples.
5.12 Cleanse the incision with sterile normal saline.
5.13 Dress wound according to physician's order.
5.14 Apply steri-strips as needed.
5.16 Document on the Daily Nurses Record (DNR) the
following:
5.16.1 Date and time
5.16.2 Condition of wound
5.16.3 Specify if alternate sutures or staples were
removed.
5.16.4 Steri-strips, if applied
5.16.5 Dressing, if any
5.16.6 Patient condition.
SC-59
5.11 Dressing protects the wound from
being infected.
5.12 To provides additional support.
5.14 To maintain wound stabilization.
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6.0 ATTACHMENTS
NA
7.1 Sterile suture removal set or staple remover.
7.2 Cleansing solution i.e. sterile normal saline.
7.3 Steri-strips.
7.4 Sterile 4X4 gauze.
7.5 Gloves non-sterile (2 pairs).
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.
NAME:
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2010
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4 of 4
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POLICY NUMBER
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TITLE:
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NURSING
SURGICAL SKIN PREPRATION SHAVING AND
PREPRATION FPOR OR.
GNR-05-17
APPROVAL DATE
EFFECTIVE DATE
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NUMBER OF PAGES
1 of 3
1.0 PURPOSE
1.1 To reduce the microbial flora of the patient’s 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.
3.1 RIGESTERD NURSE.
4.0 POLICY
4.1 To be performed by experienced nursing staff.
4.2 Verify the Physician’s 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
5.2 Assemble equipment in a clean tray.
5.1 To maintain patient safety goal.(patient
identification)
5.2 To insure smooth orderly procedure.
5.3 Instruct the patient to take a bath before shaving.
5.3 To prevent cross infection.
5.1 Identify the patient
5.3 To maintain patient right and nursing
ethics practice.
ethics practice.
5.5 To facilitate an orderly procedure
5.3 Explain procedure to the patient
5.4 Provide privacy.
5.5 Take the assembled tray to the room.
5.6 Expose the area to be shaved only.
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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.
5.7 To protect patient linen.
5.8 To prevent cross infection and to
maintain easily removal of hair.
5.9 To eliminate the possibility for abrasions
and cuts and to produce clean, smooth,
intact skin.
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 patient’s response.
6.1 Paper towels and plastic disposable bag.
6.2 Soap and water.
6.3 Small bowl.
6.4 Hair remover or shaving set.
6.5 Disposable gloves.
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DPP
TITLE:
APPLIES TO:
NURSING
PREPRATION FPOR OR.
GNR-05-17
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3 of 3
NA.
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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REVIEWED BY:
APPROVED BY:
DATE
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2010
2010
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1.0 PURPOSE
To achieve an appropriate application of elastic bandage without complication.
2.0 DEFINITION
NA
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
5.1 Inspect skin for alterations in integrity as indicated
by abrasions, discoloration, chafing, or edema.
5.2 Observe adequacy of circulation by noting surface
temperature, skin color, and sensation of body parts to
be wrapped.
5.3 Review medical record for specific
orders related to application of elastic
bandage. Note area to be covered, type
of bandage required, frequency of
change, and previous response to treatment.
5.1 Altered skin integrity contraindicates
the use of elastic bandage.
5.2 To ensure continuity of adequate
circulation.
5.4 Explain procedure to patient.
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5.5 Reinforce teaching that smooth, even, light
pressure will be applied to improve venous circulation,
prevent clot formation, reduce or prevent swelling,
immobilize arms, secure surgical dressings, and
provide pressure
5.6 Wash hands.
5.7 Assist patient to a comfortable position.
5.8 Apply bandage from distal point toward proximal
boundary using variety of turns to cover various
shapes of body parts.
5.9 Unroll and very slightly stretch bandage. Overlap
turns.
5.10 Secure first bandage before applying additional
rolls.
5.11 Evaluate distal circulation as application is
completed and at least twice during 8-hr period (note
color, warmth, pulses, and numbness).
5.12 Record bandage application and patient’s
response in nurse’s notes.
2 of 3
5.5 Improves knowledge level regarding
need for elastic bandages.
5.6 Maintain standard precaution.
5.7 Maintains comfort and dignity.
Maintains alignment. Prevents
musculoskeletal deformity.
5.8 Bandage is applied in manner that
conforms evenly to body part and
promotes venous return.
5.9 Maintains uniform bandage tension.
Prevents uneven bandage tension and
circulatory impairment.
5.10 Prevents wrinkling or loose ends.
5.11 Early detection of circulatory
difficulties ensures healthy
neuromuscular status.
5.12 Documentation of procedure
ensures continuity of care.
6.0 ATTACHMENTS
NA
7.1 Correct widths of bandages.
7.2 Dressings or splints.
7.3 Tape.
8.0 REFERENCES
Potter, P., & Perry, A. (2000). Applying an Elastic Bandage In Fundamentals of Nursing Concepts,
Process & Practice. (5th ed.) St. Louis: Mosby-Year Book, Inc.
SC-66
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NURSING
3 of 3
DATE
SC-67
2010
2010
2010

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