Postoperative Surgical Documentation

Questions and Answers

What should be observed to ensure that sterile technique has not been broken during the draping process?

Condition of the sterile linens. (correct)

Presence of a sterile field. (correct)

Patient’s comfort level.

Patient's vital signs.

What is the first step in the draping procedure after ungloving both hands?

Insert the abdominal sheet.

Instruct the patient to lift buttocks.

Place the sterile sheet on the patient.

Glove both hands. (correct)

During the aftercare of equipment, what action is taken immediately after the delivery?

Re-sterilize equipment inside the sterile towel. (correct)

Discard all used equipment.

Clean the perineal preparation tray.

Store equipment for the next patient.

What should NOT be documented in the patient's chart following final perineal preparation?

Final perineal preparation details. Signup and view all the answers

Which action should be taken if the patient is on active labor and needs to stay in the delivery room?

Adjust the table and remove the patient's legs from stirrups. Signup and view all the answers

What should the nurse do to support a woman's pushing efforts during labor?

Encourage her labor coach. Signup and view all the answers

What is the method for inserting the legging/lap towel to the patient during draping?

Grasp the towel and insert it to the left leg. Signup and view all the answers

Which should be the immediate response if a patient reports burning, discomfort, or itching during the evaluation?

Evaluate the condition of the skin. Signup and view all the answers

What should be documented postoperatively to aid in monitoring the wound?

Area and description of the surgical site Signup and view all the answers

When both gloves become contaminated during a procedure, what is the appropriate action?

Regown and reglove, or have a sterile team member do it Signup and view all the answers

What action should be taken if one glove becomes contaminated?

Use the open gloving method to reglove Signup and view all the answers

Which of the following is NOT a sign of infection at the surgical site?

Nausea Signup and view all the answers

What should be emphasized when teaching patients and their families about postoperative care?

Observe for signs of infection at the surgical site Signup and view all the answers

What is an expected outcome when proper surgical technique is maintained?

No exposure to microorganisms Signup and view all the answers

What should be assessed before donning surgical gloves?

Condition of cuticles and hands for cuts or lesions Signup and view all the answers

Which statement about operative procedure documentation is correct?

Include the role of each healthcare professional in the OR Signup and view all the answers

What is the primary purpose of drying hands thoroughly after washing?

To avoid water running onto the scrub attire Signup and view all the answers

What signs should be monitored for indicating potential wound infection post-operatively?

Redness, heat, swelling, pain, and drainage Signup and view all the answers

What should be done with the hand towel after drying hands?

Discard to prevent contamination Signup and view all the answers

During hand drying, which area of the hand should be dried first?

Cleanest area to least clean area Signup and view all the answers

How should water be turned off after hand washing to maintain sterility?

With foot or knee control Signup and view all the answers

What documentation is required following the hand washing procedure?

Recording is not required for hand washing Signup and view all the answers

What should be done if a pattern of surgical wound infections is observed?

Monitor trends and possibly culture nails and hands of staff Signup and view all the answers

How should hands and arms be positioned when entering the major room post-hand washing?

Elevated in front and away from the body Signup and view all the answers

Study Notes

Surgical Site Documentation

Record area and description of the surgical site postoperatively to establish a baseline for wound monitoring.
Utilize special forms to document names and roles of healthcare professionals present in the operating room (OR).
Document adherence to sterile technique, noting any breaches.

Unexpected Outcomes and Interventions

Contaminated gloves during a procedure warrant regowning and regloving or assistance from a sterile team member.
If one glove is contaminated, use the open gloving method to reglove.
Signs of infection include redness, heat, swelling, pain, and drainage; implement appropriate wound care when detected.

Teaching Considerations

Instruct patients and families to observe the surgical site for signs of infection post-discharge.

Performance Checklist for Gowning and Gloving Technique

Inspect hands and cuticles for cuts, lesions, or abrasions prior to donning gloves.
Choose the correct size and type of gloves and gown tailored to the procedure's requirements.

Nursing Diagnosis and Planning

Develop nursing diagnoses based on assessment data gathered preoperatively.
Expected outcomes include no breaks in surgical technique and patient protection against microorganisms.

Surgical Handwashing Protocol

Notify personnel of the initiation of surgical handwashing procedures.
Conduct thorough handwashing, ensuring flow of water from fingertips to elbows to prevent contamination.

Draping Techniques

Proper draping involves inserting towels and sheets carefully, ensuring sterility and coverage of the patient.
Encourage the patient's labor coach to support labor efforts during the draping process.

Evaluation of Techniques

Assess for breaks in sterile technique and inspect the skin condition of the patient.
Question the patient regarding any sensations of burning, discomfort, or itching.

Recording and Reporting Procedures

No documentation required for final perineal preparation and draping; record information pertaining to follow-up procedures only.
Ensure equipment used in perineal preparation is resterilized after each delivery.

Monitoring for Postoperative Infection

Observe for signs of localized wound infection within 2 to 3 days post-operation.
Monitor infection patterns, involving the hospital infection control team to trace potential sources.

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Description

This quiz focuses on the essential practices for documenting the surgical site after an operation. It covers the importance of recording baseline information for wound monitoring and the roles of healthcare professionals in the operating room. Participants will learn about maintaining sterile techniques and managing unexpected outcomes during procedures.