zNCM-33-B-ALL-LRDR-Procedures-with-checklists-2023_3b3777b91b2599c16d348987854088ae.pdf

COLLEGE OF NURSING Silliman University Dumaguete City FINAL PERINEAL PREPARATION & DRAPING IN THE DELIVERY ROOM Definition: Final Perineal Preparation is cleansing the exter...

COLLEGE OF NURSING Silliman University Dumaguete City FINAL PERINEAL PREPARATION & DRAPING IN THE DELIVERY ROOM Definition: Final Perineal Preparation is cleansing the external genitalia, upper two-thirds of the inner aspect of the thighs, lower half of the abdomen and anal region of a woman in preparation for stripping, amniotomy, and delivery. Draping procedures create an area of asepsis called sterile field. All items that come in contact with the wound must be restricted within the defined area of safety to prevent transportation of microorganisms into the open wound. The sterile field is created by placement of sterile sheets and towels in a specific position to maintain the sterility of the surfaces on which sterile instruments and gloved hands may be placed (Meeker & Rothrock, 1995). Purposes: Final Perineal Preparation: 1. To cleanse the external genitalia, upper two-thirds of the inner aspects of the thighs, lower half of the abdomen and anus. 2. To prevent infection. Draping: 1. To create an area of asepsis. Equipment: From CSR – none From Delivery Room – Perineal Preparation tray Inside Sterile Towel 1 – Round nose forceps 1 – bowl of Zephiran Chloride 1:1,000 solution 1 – bowl sterile water Sponges Outside Sterile Towel 1 – metal pitcher containing sterile water Phisohex in dispenser 1 – Single sterile glove Kelly Pad Pail Inside Sterile Pack (Separate) Buttocks sheet Abdominal sheet 2 – Lap towels STEPS RATIONALE ASSESSMENT 1. Check physician’s order or institution’s Extent area preparation depends on site of procedure for final perineal preparation. incision, nature of surgery, and physician’s 2. Inspect general condition preference.  Critical Decision Point If lesions, irritating, or signs of skin infection Preexisting lesions, irritations, or infection are present. increase chance for postoperative wound infection. 3. Assess for allergy to iodine or shellfish. Providone-iodine solutions should not be used if the client is allergic to iodine. Shellfish contain iodine. 4. Assess for bleeding tendency by Presence of bleeding tendency would reviewing patient’s medication history and contraindicate use of a razor. Medications coagulation laboratory values such as aspirin and Warfarin (Coumadin) (prothrombin time [PT], partial increase clotting time. Prednisone causes skin thromboplastin time ([PT]). to be thin and friable. 5. Assess patient’s understanding and Client may be anxious regarding procedure that acceptance of purpose for final perineal follows. preparation. NURSING DIAGNOSIS Nursing Diagnoses Risk for injection Risk for impaired Skin Integrity Disturbed Body Image Related factors are individualized based on client’s condition or needs. PLANNING 1. Identify expected outcomes following completion of procedure:  Patient’s skin is free of all hair over Skin prepared for surgical incision. perineal area.  Skin is free of visible cuts, nicks, and Less likelihood of skin infections developing. areas of inflammation.  Patient denies burning, discomfort, or Skin intact without abrasions, cuts, or allergy itching. to disinfectant used.  2. Wash hands. 3. Inspect the delivery room if equipment mentioned is in their right places. 4. Explain procedure to patient. Promotes cooperation and minimizes. IMPLEMENTATION Final Perineal Preparation: 1. Identify patient. 2. Bring patient to delivery room. 3. Put on a pair of sterile gloves. 4. Position patient comfortably on delivery Skin preparation can take several minutes. table. Patient’s legs and thighs should be comfortably 5. Adjust retractable or lower end of table placed on the stirrups. Buttocks should be in and roll it under main section of DR table. line with the edge of the table. (Lift legs of patients together). 6. Adjust Kelly pad under patient’s buttocks. Done to prevent wetting patient’s back during the procedure and to facilitate drainage to pail. 7. Adjust DR table so that patient’s buttocks For lathering Phisohex. will be at a lower level than her head. Sterile touches sterile. 8. Pour sterile water on patient’s external genitalia, thighs and lower half of the Ungloved hand is used since pitcher is abdomen. considered unsterile. 9. Open perineal preparation tray. 10. Replace clean glove of dominant hand with another sterile glove. 11. Pour Phisohex on patient’s genitalia, thighs and lower stomach with ungloved hand. 12. Get a sterile sponge, dip it in bowl with To keep scrubbed area and sterile equipment sterile water. sterile. 13. Scrub patient using circular motion, Observe sterile technique. following sequence below: a. Center (vestibule) or vulva b. Labia (minora then majora) c. Groin d. Abdomen e. Thighs f. Buttocks g. Anus 14. Flush scrubbed area with sterile water. 15. Gets a sponge using sterile forceps. Dip it in sterile water and wipe areas which are still soapy using technique. 16. Get another sponge, dip it in Zepphiran Chloride 1:1,000 and pass over scrubbed areas following sequence in step no. 13. 17. Place a dry, quilted pad under patient’s Determines if there is remaining hair of skin or buttocks. if skin was cut. Indicates presence of skin cut irritation, or 18. Cover scrubbed area with sterile towel allergic response. while waiting for doctor. 19. Cover sterile tray. 20. Do aftercare of equipment. 21. Ungloved both hands. Draping: 1. Glove hands. 2. Instruct patient to lift buttocks. 3. Insert buttocks sheet and withdraw hands immediately. 4. Insert right hand on upper folded portion of the left legging/lap towel while left hands is also inserted under folded part of it. 5. Grasp the legging/lap towel with both hands and inserted to the left leg of the patient then drop. 6. Insert the right legging/lap towel to the left leg by using technique. 7. Insert both gloved hands to the folded part of the abdominal sheet with palms facing down. 8. Lift abdominal sheet and let it drop then place it over the patient’s abdomen. Make a fold of the part held by both hands. EVALUATION 1. Observe that there is no break in sterile technique. 2. Inspect condition of skin. 3. Question if patient feels burning,  discomfort, or itching RECORDING AND REPORTING No charting is done for final perineal preparation and draping. However charting is done for procedure that follows. NOTE: FINAL PERINEAL PREPARATION:  If patient is for vaginal stripping or amniotomy, clean patient’s perineum with sterile water after the procedure and accompany patient to labor room.  If patient is on active labor and has to stay in DR, readjust the lower end of the table and remove patient’s legs from strirrups.  Equipment inside the sterile towel, in the perineal preparation tray, are resterilized every after the delivery unless there are other patients on active labor. DRAPING:  The nurse also supports the woman’s pushing efforts during this time and encourages the woman’s labor coach. After the woman is draped, no part of the exposed side of the sterile linen (or paper) covering the patient should be touched by anyone most properly gloved or gowned.  If the nurse needs to palpate contractions or apply fundal or suprapubic pressure, she must reach under the sterile drape, avoiding the exposed perineum.  After the infant is born, if she is placed on her mother’s abdomen, the nurse may reach under the covering drape and using the drape as a hand guard, hold on to an arm or leg to help give support while newborn’s airway is aspirated or the cord is clamped (Novak & Broom, 1995).  COLLEGE OF NURSING Silliman University Dumaguete City PERFORMANCE CHECKLIST FINAL PREPARATION & DRAPING IN THE DELIVERY ROOM Student: _________________________________ Instructor: _______________________________ Instructor’s Signature: ____________________ Date: _______________ 1 2 3 4 ASSESSMENT 1. Check physician’s order or institution’s procedure for final perineal preparation. 2. Inspect general condition. 3. Assess for allergy to iodine or shellfish. 4. Assess for bleeding tendency by reviewing patient’s medication history and coagulation laboratory values (prothrombin time [PT], partial thromboplastin time [PTT]). 5. Assess patient’s understanding and acceptance of purpose for final perineal preparation. NURSING DIAGNOSIS Develops appropriate nursing diagnosis based on assessment data. PLANNING 1. Identify expected outcomes following completion of procedure:  Patient’s skin is free of all hair over perineal area.  Skin is free of visible cuts, nicks, and areas of inflammation.  Patient denies burning, discomfort, or itching. 2. Wash hands. 3. Inspect the delivery room if equipment mentioned is in their right places. 4. Explain procedure to patient. IMPLEMENTATION Final Perineal Preparation: 1. Identify patient. 2. Bring patient to delivery room.  3. Put on a pair of clean gloves. 4. Position patient comfortably on delivery table. 5. Adjust retractable or lower end of table and roll it under main section of DR table. 6. Adjust Kelly pad under patient’s buttocks. 7. Adjust DR table so that patient’s buttocks will be at lower level than her head. 8. Pour sterile water on patient’s external genitalia, thighs and lower half of the abdomen. 9. Open perineal preparation tray. 10. Replace clean glove of dominant hand with another sterile glove. 11. Pour Phisohex on patient’s genitalia, thighs and lower stomach with ungloved hand. 12. Get a sterile sponge, dip it in bowl with sterile water. 13. Scrub patient using circular motion, following sequence below:  Center (vestibule) or vulva  Labia (minora then majora)  Groin  Abdomen  Thighs  Buttocks  Anus 14. Flush scrubbed area with sterile water. 15. Get a sponge using sterile forceps. Dip it in sterile water and wipe areas which are still soapy using technique. 16. Get another sponge, dip it in Zephiran Chloride 1:1,000 and pass over scrubbed areas following sequence in step no. 13. 17. Place a dry, quilted pad under patient’s buttocks. 18. Cover scrubbed area with sterile towel while waiting for doctor. 19. Cover sterile tray. 20. Do aftercare of equipment. 21. Ungloved both hands. DRAPING: 1. Glove hands. 2. Instruct patient to lift buttocks. 3. Insert buttocks sheet and withdraw hands immediately.  4. Insert right hand on upper folded portion of the left legging/lap towel while left hand is also inserted under folded part of it. 5. Grasp the legging/lap towel with both hands and inserts to the left leg of the patient then drop. 6. Insert the right legging/lap towel to the left leg by using technique. 7. Insert both gloved hands to the folded part of the abdominal sheet with palms facing down. 8. Lift abdominal sheet and drop then place it over the patient’s abdomen. Makes a fold of the part held by both hands. EVALUATION 1. Observe that there is no break in sterile technique 2. Inspect condition of skin. 3. Question if patient feels burning discomfort or itching. RECORDING AND REPORTING No charting is done for final perineal preparation and draping. However charting is done for procedure that follows.  COLLEGE OF NURSING Silliman University Dumaguete City GOWN AND GLOVE TECHNIQUE Definition: The procedure of putting on a sterile gown and glove. Purpose: The permit the wearer to come within the sterile field and carry out and assist in an operative procedure. Equipment: Sterile: Hand towel Nurse’s and doctor’s gown Needed glove with pack of powder (open glowing technique) STEPS RATIONALE ASSESSMENT 1. Inspect condition of cuticles and hands Lesions harbor microorganisms and may for cuts, open lesions, or abrasions. prevent nurse from performing procedure. 2. Check fingernails per procedure. Fingernails harbor microorganisms. 3. Choose proper size and type of glove. ILL-fitting gloves impede the ability to grasp Latex-free glove is preferred. objects and provide an opportunity for needle punctures. Skin sensitivities may occur with latex gloves. Powder in latex gloves can be inhaled and cause an allergic response. 4. Choose proper size and type of gown. ILL-fitting gown may impede movement of NURSING DIAGNOSIS nurse’s extremities. Nursing Diagnoses Risk for infection Related factors are individualized based on patient’s condition or needs. PLANNING 1. Identify expected outcomes following completion of procedure:  No break in surgical technique will occur. Patient is not exposed to Nurse maintains aseptic practice and does not  microorganisms. contaminate gown or gloves. 2. Prepare for surgical handwashing. Alert personnel or treatment area that Circulating nurse or technician must be scrubbing is to begin. (Personnel will available to assist nurse with gowning once prepare gown and glove packs.) scrub is completed. IMPLEMENTATION 1. Perform surgical hand scrub before putting on gown and gloves. 2. Enter operating suite, keeping elbows bent away from scrub suit and hands Prevents hands from touching contaminated above waist. Dry hands with sterile object. Prevents wetting scrubs with water. towel provided by circulating nurse 3. Ask circulating nurse to assist by opening sterile gown pack (package Gown’s outer surface remains sterile in inside out) and glove package on a package. clean, dry flat surface. 4. Reach down to sterile gown package; pick up the gown, grasping the inside The hands are not completely sterile. The inside surface of gown at the collar. surface of the gown will contact the skin’s surface and is thus considered contaminated. 5. Lift folded gown directly upward and Provides wide margin safety, avoiding step back away from table. contamination of gown. 6. Holding folded gown, locate Clean hands may touch inside of gown without neckband. With both hands, grasp contaminating outer surface. inside front of gown just below neckband. Outside of gown remains sterile. 7. Hold gown at arm’s length away from your body. Allow gown to unfold, keeping inside of gown toward body. Do not touch outside of gown with bare hands. Careful application prevents contamination. 8. With hands at shoulder level, slip both Gown covers hands to prepare for closed arms into armholes simultaneously. gloving. Ask circulating nurse to bring gown over shoulders by reaching inside to arms seams. Gown is pulled on, leaving seams covering hands. Gown must completely enclosed underlying 9. Have circulating nurse securely tie garments. back of the gown at collar and waist. 10. Apply gloves A. Open Glove Technique Prevents inner glove from accidentally opening a. Remove outer glove package wrapper  by carefully separating and peeling and touching contaminated objects. apart sides. b. Grasp inner package and lay it on Sterile objects held below waist is clean, dry, flat surface at waist level. contaminated. Inner surface of glove package is Open package, keeping gloves on sterile. wrapper’s inside surface. c. Identify right and left glove. Each Proper identification of gloves prevents glove has a cuff approximately 5 cm contamination by improper fit. Gloving of (2 inches) wide. Glove dominant hand dominant hand first improves dexterity. first. d. With thumb and first two fingers of no Inner edge of cuff will lie against skin and thus dominant hand, grasp edge of cuff of is not sterile. gloves for dominant hand. Touch only glove’s inside surface. e. Carefully pull glove over dominant If glove’s outer surface touches hands or wrist, hand, leaving cuff and being sure cuff it is contaminated. does not roll up to the wrist. Be sure thumb and fingers are in proper spaces. Cuff protects gloved fingers. Sterile touching f. With gloved dominant hand, slip sterile prevents glove contamination. fingers underneath second glove’s Contact of gloved hand with exposed hand cuff. results in contamination. g. Carefully pull second glove over non dominant hand.  Critical Decision point Do not allow fingers and thumb of gloved dominant hand to touch any part of exposed non dominant hand. Keep thumb of dominant hand abducted back. h. After second glove is on, interlock hands together, above waist level. The cuffs usually fall down after application. Be sure to touch only sterile sides. i. Place thumb on left hands across its palm and anchor cuff. j. Adjust sleeves at wrists and bring glove cuff over snugly. Avoid touching exposed skin (Observe glove-to-glove and skin-to-skin technique with the wrist cuff of gown and make a pleat before bringing the  glove cuff over it). k. Do the same for the right hand. Hands remain clean. Sterile gown cuff will l. Wash off powder from gloved hands touch sterile glove surface. in sterile basin provided for. Sterile gown touches sterile glove. B. Closed Glove Technique a. With hands covered by gown sleeves, Position glove for application over cuffed hand, open inner sterile glove package. keeping glove sterile. b. With non dominant hand inside gown cuff, pick up gloves for the dominant hand by grasping folded cuff. c. Extend dominant forearm with palm up and place palm of glove against palm of dominant hand. Glove fingers will point toward elbow. d. While holding glove cuff through gown with dominant hand on which it Seal created by glove cuff over gown prevents is placed, grasp back of glove cuff exit of microorganisms over operative sterile with non dominant hand and turn field. glove cuff over end of dominant hand and gown cuff. e. Grasp top of glove and underlying Sterile touches sterile. gown sleeve with covered non dominant hand. Carefully extend fingers into glove, being sure glove’s Ensures that nurse has full dexterity while using cuff covers gown’s cuff. gloved hand. f. Glove non-dominant hand in same manner, reversing hands. Use gloved dominant hand to pull on glove. g. Be sure fingers are fully extended pin to both gloves. Assisting Physician with Gowning 1. Offer hand towel to the physician. Protect gloved hand with towel from touching physician’s skin. 2. Insert gloved hands under neckline with the gown’s rough edge facing you. 3. Lift gown from the table and slightly shake it to loosen gown. Edges of autoclaved gown sticks together. 4. Step away far enough from non sterile objects. Spread gown and extend to the physician (Physician insert arms  into respective armholes and circulating nurse ties belt and neck band). 5. Adjust sleeves till wrist cuffs are well fitted. Assisting Physician with Gloving 1. Open glove envelope. 2. Pick pack of powder, open, and sprinkle powder on physician’s hands. 3. Remove right hand glove from envelope and inflate. 4. Serve glove to physician. Remember to stand firmly and avoid touching physician’s hand. a. Hold the glove with palm facing the physician. b. Insert fingers under folded cuff and extend thumbs out. c. Stretch cuff sufficiently for the doctor to insert his hand. d. Release glove (wait for physician’s signal). 5. Serve the left glove in the same manner. 6. Give glove envelope PRN. This is There is no break in sterile technique. Nurse is done only when operation is to tale not required to reglove or apply a second gown. place immediately. The physician protects gloved hands inside this envelope. EVALUATION Observe for break in sterile technique. RECORDING AND REPORTING 1. Record the area and description of surgical site postoperatively to provide baseline for monitoring wound. 2. Special forms are available for operative procedures to record name and role of each health care professional in OR. Document that  either no breach in sterile technique was observed or reported or that technique was broken. UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS  Both gloves become contaminated during a procedure. Regown and reglove or have a sterile member of the team do the regloving.  One glove becomes contaminated during a procedure. Use open gloving method to reglove.  Patient develops sign of infection – redness, heat, swelling, pain, and drainage at surgical site, as a result of contamination of glove. Implement appropriate wound care. TEACHING CONSIDERATIONS  Instruct patient and family or significant other to observe surgical site for signs of infection.  COLLEGE OF NURSING Silliman University Dumaguete City PERFORMANCE CHECKLIST GOWNING AND GLOVING TECHNIQUE Student: _________________________________ Instructor: _______________________________ Instructor’s Signature: ____________________ Date: _______________ ASSESSMENT 1 2 3 4 1. Inspected condition of cuticles and hands for cuts, open lesions, or abrasions. 2. Checked fingernails per procedure. 3. Chose proper size and type of gloves. 4. Chose proper size and type of gown. NURSING DIAGNOSIS Developed appropriate nursing diagnoses based on assessment data. PLANNING 1. Identify expected outcomes following completion of procedure:  No break in surgical technique will occur. Patient is not exposed to microorganisms. 2. Prepared for surgical handwashing. Alert personnel or treatment area that scrubbing is to begin. (Personnel will prepare gown and glove packs). IMPLEMENTATION 1. Perform surgical hand scrub before putting on gown and gloves. 2. Enter operating room, keeping elbows bent away from scrub suit and hands above waist. Dries hands with sterile towel provided by circulating nurse. 3. Ask circulating nurse to assist by opening sterile gown pack (package inside out) and glove package on a clean, dry flat surface. 4. Reach down to sterile gown package: pick up the gown, grasping the inside surface of gown  at the collar. 5. Lift folded gown directly upward and steps back away from table. 6. Holding folded gown, locate neckband. With both hands, grasps inside front of gown just below neckband. 7. Hold gown at arm’s length away from your body. Allow gown to unfold, keeping inside of gown toward body. Do not touch outside of gown with bare hands. 8. With hands at shoulder level, slip both arms into armholes simultaneously. Asks circulating nurse to bring gown over shoulders by reaching inside to arm seams. Pull gown on, leaves seams covering hands. 9. Have circulating nurse securely tie back of the gown at collar and waist. 10. Apply gloves. A. Open Glove Technique a. Remove outer glove package wrapper by carefully separating and peeling apart sides. b. Grasp inner package and lays it on clean, dry, flat surface at waist level. Open package, keeping gloves on wrappers inside surface. c. Identify right and left glove. Each glove has a cuff approximately 5 cm (2 inches) wide. Glove dominant hand first. d. With thumb and first two fingers of no dominant hand, grasp edge of cuff of glove for dominant hand. Touches only glove’s inside surface. e. Carefully pulls glove over dominant hand, leaving cuff and being sure cuff does not roll up to the writs. Make sure thumb and fingers are in proper spaces. f. With gloved dominant hand, slips finger underneath second glove’s cuff. g. Carefully pull second glove over non dominant hand. h. After second glove is on, interlocks hands together, above waist level. The cuffs usually fall down after application. Touches only sterile sides. i. Place thumb on left hand across its palm and anchors cuff.  j. Adjust sleeves at wrists and brings glove cuff over snugly. Avoids touching exposed skin (Observes glove-to-glove and skin-to-skin technique with the writ cuff of gown and makes a pleat before bringing the glove cuff over it). k. Do the same for the right hand. B. Close Glove Technique a. With hands covered by gown sleeves, opens inner sterile glove package. b. With non dominant hand inside gown cuff, picks up glove for the dominant hand by grasping folded cuff. c. Extend dominant forearm with palm up and places palm of glove against palm of dominant hand. d. While holding glove cuff through gown with dominant hand on which it is placed, grasps back of glove cuff with non dominant hand and turns glove cuff over end of dominant hand and gown cuff. e. Grasp top of glove and underlying gown sleeve with covered no dominant hand. Carefully extends fingers into glove, make sure glove’s cuff. f. Glove non dominant hand in same manner, reversing hands. Uses gloved dominant hand to pull on glove. g. Make sure fingers are fully extended into both gloves. Assisting Physician with Gowning 1. Offered hand towel to the physician. Protects gloves hand with towel from touching physician’s skin. 2. Insert gloves hands under neckline with the gown’s rough edge facing you. 3. Lift gown from the table and slightly shake it to loosen gown. Edges of autoclaved gown sticks together. 4. Step away far enough from no sterile objects. Spreads gown and extends to the physician (Physician inserts arms into respective armholes and circulating nurse ties belt and neck band). 5. Adjust sleeves till wrist cuffs are well fitted. Assisting Physician with Glowing  1. Open glove envelope. 2. Pick pack of powder. Open, and sprinkles powder on physician’s hands. 3. Remove right hand glove from envelope and inflate. 4. Serve glove to physician. Stands firmly and avoids touching physician’s hand. a. Hold the glove with the palm facing the physician. b. Insert fingers under folded cuff and extends thumbs out. c. Stretch cuff sufficiently for the doctor to insert his hand. d. Release glove (wait for physician’s signal). 5. Serve the left glove (waits for physician’s signal). 6. Give glove envelope PRN. EVALUATION Observe for break in sterile technique. RECORDING AND REPORTING Record the area and description of surgical site postoperatively baseline data for monitoring wound.  COLLEGE OF NURSING Silliman University Dumaguete City INITIAL CARE OF THE NEWBORN Definition: Care given to a baby immediately after birth. Purposes: 1. To cleanse the baby. 2. To provide warmth and comfort. 3. To prevent infection. Equipment: Sterile baby set with following contents: 2 Blankets 4 Cotton applicators 2 Diapers 2 slit sponges Dress 2 sponges 3 Cotton Balls 1 wash cloth Materials to be added: Sterile 1 Pair of tissue scissors 1 Pean 1 Medicine dropper 1 Latex band Other equipment found in the nursery cart Bottle of sterile cotton balls Bottle of sterile sponges Bottle of cotton applicators Rectal thermometers Phisohex Sterile latex band Tape measure Fine toothed comb Safety pins Waste receptacles or kidney basin Bottle of silver nitrate 1 Weighing scale 2 basins of lukewarm water STEPS RATIONALE ASSESSMENT 1. Wash hands. Reduces transmission of microorganisms. 2. Assemble of equipments: 1. Needed equipment: a. From DR a. Equipments from DR 1. Baby set – add materials mentioned  above. 2. Procedure can either be done in the nursery or in the DR table (Nursery is preferable). b. From the nursery cart. 3. Check if all the materials mentioned above are available the place where the procedure is to be done. Make it near the nurse’s station. 3. Put on a pair of gloves As part of universal precaution. 4. Transfer baby to worktable. Phisohex is never used in the baby’s face. 5. Clean baby’s face with care using wash Hold baby in “football hold”. cloth wet with water. 6. Apply phisohex to baby’s head and work a good lather. 7. Rinse head. Remove all phisohex and Use the fine toothed comb. drift from the head. 8. Give eye treatment: (Fresh silver nitrate. Opened bottle is good for a. Instill Terramycin ophthalmic 24 hours only). Use two cotton in opening ointment to each eye. babys’ eyes. Turn baby’s head to sides when instilling. 9. Apply phihosex to other part of the baby’s body in this order: neck, arms (armpit), chest, abdomen, back lower Don’t apply phisohex to the hands. extremities, buttocks and anus. 10. Immerse baby in the first basin of water. Hold baby in “football technique”. Rinse baby in another basin Keep end of baby’s cord out of water edge. Be of clean lukewarm water. careful not to stretch with cord. 11. Put baby in a new blanket and wipe dry. Cord care and application of latex band. a. Cord care about 2 inches from the base with phisohex going up. Area around the base (1 ½ inches in diameter) should also be cleansed in circular motion going out from the base. b. Put a slit sponge around base of the cord. c. Insert 1 latex band into the pean, clamp cord about 1 inch above the cord. d. Cut cord above the clamped pean. Before inserting into the pean test strength of e. Pull latex off pean and pull down to latex band by pulling the thread. base of cord. f. Remove thread from latex by inserting Be careful that pean does not get unclamped.  scissors in between two threads and Avoid pulling cord or putting traction on the cutting one thread. Then pull thread. cord. g. Clean stump with phisohex. Then follow it with cotton applicators moistened in sterile water. h. Replace slit sponge with another one. i. Remove pean. j. Dress cord stump with sponge. 6. Clean genitalia of baby. If female use cotton applicator moistened in sterile water. If male, clean penis with phisohex and cotton pledgets. 7. Weigh baby. Line weighing scale with diaper and balance it. Weigh baby. 8. Measure head and chest circumference. Place tape measure around the head encircling 9. Measure length of the body. the forehead over the brow and occiput to heel keeping baby’s body as straight as possible. 10. Dress baby. 11. Take rectal temperature. 12. Place identification band at the ankle. Place family name of the baby and sex, time delivered and date. Take footprints. 13. Place him in prepared crib. 14. Give konakion 1mg to thigh (for normal newborns and 0.5 mg). 15. Return things to proper places. 16. Wash articles that need washing. 17. Discard contents of water receptacles into garbage container. 18. Put all s oiled linens into hamper. 19. Clean used basins and return to proper places. 20. Endorse to nursery nurse: a. Include the procedure done: 1. Initial care using phisohex. 2. Crede’s prophelaxis 3. Cord care 4. Konakion injection 21. Record/chart procedures and Charting: observations. 1. Complete charting of baby’s chart (blue sheet). Chart procedures at the back of the blue sheet. a. Procedures b. Length and circumference of head and chest. c. Cord length. d. 10 % weight loss. e. Weight. f. Date and time delivered. g. Relevant observation h. Temperature, rectal.  COLLEGE OF NURSING Silliman University Dumaguete City Student: _________________________________ Instructor: _______________________________ Instructor’s Signature: ____________________ Date: _______________ PERFORMANCE CHECKLIST INITITAL CARE OF THE NEWBORN 1 2 3 4 1. Wash hands. 2. Assemble equipment: a. From DR b. From the nursery cart 3. Put on a pair of gloves. 4. Transfer baby to work table. 5. Clean baby’s face with care using wash cloth wet with water. 6. Apply phisohex to baby’s head and make a good lather. 7. Rinse head. Removes all phisohex and drift from the head. 8. Give eye treatment: a. Instill Terramycin ophthalmic ointment to each eye. 9. Apply phihosex to other part of the baby’s body in this order: neck, arms especially axillae, chest, abdomen, back lower extremities, buttocks and anus. Makes a good lather. 10. Immerse body in the first basin of water. Hold baby in “football technique”. Rinses baby in another basin of clean lukewarm water. 11. Put baby in a new blanket and wipes until dry. 12. Cord care and application of latex hand. a. Clean cord about 2 inches from the base with phisohex going up. Cleans area around the base (1 ½ inches in diameter) in circular motion going out from the base. b. Put a slit sponge around base of the cord.  c. Insert 1 latex band into the pean, clamps cord about 1 inch above the base of the cord. d. Cut cord above the clamped pean using sterile tissue scissors. e. Pull latex off pean and pull down to base of cord using sterile tissue scissors. f. Remove thread from latex by inserting scissors in between two threads and cutting one tread then pulls the tread. g. Clean stump with phisohex. Then follows it with cotton applicators moistened in sterile water. h. Replace slit sponge with another one. i. Remove pean. j. Dress the cord stump with sponge. 13. Clean genitalia of baby. 14. Weigh baby. 15. Measure head and chest circumference. 16. Measure length of the body. 17. Dress the baby. 18. Take rectal temperature. 19. Place identification band at the ankle with the following: Family name of the baby and sex, time delivered and date. Take footprints. 20. Place baby in prepared crib. 21. Give Konakion 1mg or Menodione Na Bisulphate 1 mg intramuscular to thigh. 22. Return things to proper places. 23. Wash articles that need washing. 24. Discard contents of water receptacles into garbage container. 25. Put all soiled linens into hamper. 26. Clean used basins and return to proper places. 27. Endorse to nursery nurse: a. Include the procedure done 1) Include the procedure done. 2) Crede’s prophylaxis. 3) Cord care. 4) Konakion injection. 28. Record/chart procedure and observations. EVALUATION  1. Observes the patient for signs of localized wound infection (usually occurs 2 to 3 days post-op). RECORDING AND REPORTING 1. No recording is required for hand washing. Record area and description of surgical site postoperatively to provide baseline for monitoring wound.  COLLEGE OF NURSING Silliman University Dumaguete City SURGICAL HAND SCRUB Definition: The removal of as many dirt and bacteria as possible from the hands and arms by mechanical washing and application of antiseptic before taking in surgical procedure. Purpose: 1. Remove debris and transient organisms from the rates, hands, and forearms. 2. Reduce the resident microbial count to a minimum. 3. Inhibit rapid rebound growth of microorganisms. 4. Minimize regrowth of microorganisms on hands and reduce contamination of the operative site by recognized or unrecognized breaks in surgical gloves. Equipment:  Toilet soap in a soap dish  Betadine cleanser in a dispenser  Hand Brush  Sink with knee operated control Note: The hand brushes are soaked in a sterile container with untinted zephiran solution. STEPS RATIONALE ASSESSMENT 1. Follow institution’s policy regarding Guidelines vary regarding ideal time needed required length of time for hand wash. for surgical scrub. 2. Be sure fingernails are short, clean and Long nails and chipped or old polish increase healthy. Artificial nails should be number of bacteria residing on nails. Long removed. fingernails can puncture gloves, causing contamination. Artificial nails may harbor  Critical decision Point: gram-negative microorganisms and fungus. Nail polish should be removed if chipped or worn longer than 4 days because there is a tendency after that time for nails to harbor greater numbers of bacteria (AORN, 1999b). 3. Assess for presence of allergies to soap Reporting allergies to soap or disinfectants or disinfectants. Report such to the may prevent hypersensitivity reactions. clinical instructor and O.R. Supervisor immediately. 4. Inspect condition of cuticles, hands and Cuts, abrasions, exudative lesions, and forearm for presence of abrasions, cuts or handnails tend to ooze serum, which may  open lesions. contain pathogens. Broken skin permits microorganisms to enter various layers of the skin, providing deeper microbial breeding grounds (AORN, 1999b). 5. Be sure if wearing a two-piece pant and Prevents brushing against sterile area. top scrub suit, that the top is secured at the waist and tucked into the pants. NURSING DIAGNOSIS Nursing Diagnoses Risk of infection Risk for injury Related factors are individualized based on patient’s condition or needs. Indicates microorganisms are not transferred to PLANNING the patient and sterile field. 1. Identify expected outcomes following completion of procedure: Patient will not develop signs of surgical wound infection. 2. Remove watch, rings, and bracelets. Jewelry harbors microorganisms and interferes with access to all surfaces of skin to be cleaned. 3. Wash hands. Reduces transfer of microorganisms. 4. Prepare equipment. Ensures availability before the procedure. 5. Be sure sleeves are above elbows and Scrubbed hands and arms can become uniform is fitted or tucked at waist. contaminated by brushing against loose garments. IMPLEMENTATION 1. Put on surgical attire: shoe covers, cap, Masks prevent escape into air of facemask, and protective eyewear. microorganisms that can contaminate hands. Other protective wear prevents exposure to blood and body fluid splashes during the procedure. 2. Turn on water using knee or foot Knee or foot controls prevent contamination of controls. hands after scrub. 3. Wet hands and arms under running water Water runs by gravity from fingertips to and lather with detergent up to 2 inches elbows. Hands become cleanest part of upper  above the elbows. (Hands need to be held extremity. Keeping hands elevated allows above elbows at all times). water to flow from least to most contaminated areas. Washing a wide area reduces risk of contaminating overlying gown that the nurse later applies. 4. Under running water, clean under nails of Removes dirt and organic material that harbor both hands with orange stick. Discard large numbers of microorganisms. after use. 5. Rinse hands and arms thoroughly under Rinsing removes transient bacteria from running water. Remember to keep hands fingers, hands, and forearms. above elbows. 6. Pick one brush and rinse off disinfectant under running water using forceps provide for. 7. Saturate brush with antimicrobial detergent and get enough solution to spread over both hands and arms. 8. Holding brush perpendicular, scrub the Scrubbing loosens resident bacteria that adhere palm, each side of the thumb, and fingers, to skin surfaces. Ensures coverage of all and the posterior side of the hand with 10 surfaces. Scrubbing is performed from cleanest strokes each. The arm is mentally divided area (hands) to marginal area (upper arms). into thirds and each third is scrubbed 10 times. Entire scrub should last at least 3 minutes (AORN, 1999b). Rinse brush and repeat the sequence for the other arm. 9. Rinse brush as well as both hands and arms. 10. Saturate brush with betadine and spread solution to both hands and forearms. 11. Holding brush perpendicular, scrub the palm, each side of the thumb, and fingers, and the posterior side of the hand with 10 times. Entire scrub should last at least 2 After touching skin, brush is considered minutes (AORN, 1999b). Rinse brush contaminated. Rinsing removes resident and repeat the sequence for the other arm. bacteria. Prevents accidental contamination. 12. Drop brush and rinse hands and arms thoroughly allowing water to flow from fingertips down to elbow. Turn off water with foot or knee control and back into room entrance with hands elevated in front and away from the body. 13. Enter major room. 14. Bending slightly forward at the waist, pick a sterile hand towel. Step back from the table and slightly leaning forward,  dry one hand thoroughly moving from fingers to elbow. Dry in a rotating motion. Dry from cleanest to least clean area. 15. Repeat drying method for other hand, Drying prevents chapping and facilitates using a different area of the towel or a donning of gloves. Leaning forward prevents new sterile towel. accidental contact of arms with scrub attire. 16. Discard towel. Prevents accidental contamination. EVALUATION Observe the patient for signs of localized Signs of infection include redness, heat, wound infection (usually occurs 2 to 3 days swelling, pain, and drainage. post-op). RECORDING AND REPORTING No recording is required for hand washing. Record area and description of surgical site postoperatively to provide baseline for monitoring would. UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS  Redness, heat, swelling, pain, or drainage may develop at surgical site as a result of infection. Institute appropriate would care.  In the event a pattern of surgical would infections occurs, the hospital infection control team will monitor trends from the opening rooms in an effort to trace origin. This may include cultures of nails and hands of staff, soap dispensers, etc.  COLLEGE OF NURSING Silliman University Dumaguete City PERFORMANCE CHECKLIST THE SURGICAL HAND SCRUB Student: _________________________________ Instructor: _______________________________ Instructor’s Signature: ____________________ Date: _______________ 1 2 3 4 ASSESSMENT 1. Follow institution’s policy regarding required length of time for hand wash. 2. Make sure fingernails are short, clean and healthy. 3. Assess for presence of allergies to soap or disinfectants. Resort such to the clinical instructor and O.R. Supervisor immediately. 4. Inspect condition of cuticles, hands, and forearm for presence of abrasions cuts, or open lesions. 5. Make sure if wearing a two-piece pant and top scrub suit that the top is second at the waist and tucked into the pants. NURSING DIAGNOSIS Develops appropriate nursing diagnoses based on assessment data. PLANNING 1. Identify expected outcomes following completion of procedure:  Patient will not develop signs of surgical wound infection. 2. Remove watch, rings, and bracelets. 3. Wash hands. 4. Prepare equipment. 5. Make sure sleeves are above elbows and uniform is fitted or tucked at waist. IMPLEMENTATION 1. Put on surgical attire: shoe covers, cap facemask, and protective eyewear. 2. Turn on water using knee or foot controls. 3. Wet hands and arms under running water and lather with detergent up to 2 inches above the elbows. (Hands are held above elbows at all times). 4. Under running water, clean under nails of both hands with orange stick. Discard after use. 5. Rinse hands and arms thoroughly under running water. Keeps hands above elbows. 6. Pick one brush and rinse off disinfectant under running water using forceps provided for. 7. Saturate brush with antimicrobial detergent and gets enough solution to spread over both hands and arms. 8. Hold brush perpendicular, scrubs the palm, each side of the thumb, and fingers, and the posterior side of the hands with 10 strokes each. The arms are mentally divided into thirds and each third is scrubbed 10 times. Entire scrub last at least 3 minutes (AORN, 1996b). Rinses brush and repeats the sequence for the other arm. 9. Rinse brush as well as both hands and arms. 10. Drop brush as well as both hands and arms thoroughly allowing water to flow from fingertips down to elbow. Turn off water with foot or knee control and back into room entrance with hands elevated in front and away from the body. 11. Enter major room. 12. Bend slightly forward at the waist, pick a sterile hand towel. Step back from the table and slightly leaning forward, dry one hands thoroughly moving from fingers to elbow. Dries in a rotating motion. Dry from cleanest to least clean area. 13. Repeat drying method for other hand, using a different area of the towel or a new sterile towel.  COLLEGE OF NURSING Silliman University Dumaguete City PERINEAL SHAVE Purpose: To clean the external genitalia in preparation for delivery by shaving the public and/or Perineal hair with a razor and antiseptic and/or sudsing solution in order to: 1. Prevent infection 2. Make possible episiotomy repair easier. 3. Aid in postpartum observation and care of the area. Set-Up: Provide individual equipment for each patient or equipment should be such in a way that no cross infection can take place. Provide for:  Privacy  Adequate lighting  A waterproof pad under the patient’s hips to protect the bed  A supply of clean, warm water  An antiseptic solution  A sharp safety razor  Two or three dry cotton balls or gauze compresses to help pull back on the skin as ir is being shaved and to clean the labial folds  An irrigation pitcher and/or folded soft paper or cloth towels to help rinse off the soapy solution and dry the area  Several paper towels or a plastic bag receive the waste in a convenient manner and intermittently help to clean off the razor  Clean plastic gloves for the nurse’s use during the procedure  Mask (with goggles if possible) for nurse STEP RATIONALE ASSESSMENT 1. Check physician’s order or institution’s Extent area for hair removal depends on site of procedure for shaving perineum. incision, nature of surgery, and physician’s preference. 2. Inspect general condition Preexisting lesions, irritations, or infection  Critical Decision Point increase chance for postoperative wound If lesions, irritation, or signs of skin infection. infection and present, shaving should not be done. 3. Assess for allergy to iodine or shellfish. Povidone-iodine solutions should not ne used if client is allergic to iodine. Shellfish contain iodine. Presence of bleeding tendency would 4. Assess for bleeding tendency by reviewing contraindicate use of a razor. Medications such patient’s medication history and  coagulation laboratory values (prothrombin as aspirin and warfarin (Coumadin) increase time [PT], partial thromboplastin time clotting time. Prednisone causes skin to be thin [PTT]). and friable. 5. Assess patient’s understanding and acceptance of purpose for hair removal. Client may be anxious regarding removal of  Critical Decision Point hair and implications regarding change in Certain cultures and religious groups have appearance. restrictions on removal and disposal of body hair. The nurse should ask client and/or family. NURSING DIAGNOSIS Nursing Diagnoses Acute pain Risk for Infection Risk fro Impaired Skin Integrity Disturbed Body Image Related factors are individualized based on client’s condition or needs. PLANNING 1. Identify expected outcomes following completion of procedure:  Patient’s skin is free of all hair over perineal area.  Skin is free of visible cuts, nicks, Skin prepared for surgical incision. and areas of inflammation. Less likelihood of skin infections developing.  Patient denies burning, discomfort, Skin intact without abrasions, cuts, or allergy or itching. to disinfectant used. Reduces transmission of microorganisms. 2. Wash hands. 3. Prepare equipment at patient’s bedside. Promotes cooperation and minimizes anxiety. 4. Explain procedure, extent of hair removal, and rationale for removal of hair. IMPLEMENTATION 1. Identify patient. Provides client privacy. Bed position prevents 2. Close room doors or bedside curtains; raise nurse from having to bend over for long bed to high position, and position lamp or periods. Promotes correct body mechanics and extra light source. Screen the patient. The decreases back injury. Direct and tangential sheet may be over the lower legs and feet. lighting enhances visual inspection of skin surface. 3. Position patient comfortably. The gown Hair removal and skin preparation can take turned up to just above the perineal hairline several minutes. Nurse should have easy giving adequate space to work. Have the access to hard-to-reach areas. Prevents patient bend her knees and drop her legs unnecessary exposure of body parts. sideways – heels toward one another. So that no shadows are cast. 4. If possible, place the light (wall or gooseneck lamp) on opposite of bed from where you will stand Use of disposable gloves safeguards patient 5. Apply disposable gloves. and nurse, minimizing nurse’s exposure to blood-borne pathogens. Prevents soiling of bed linens. 6. Wet Shave: Prevents unnecessary exposure of body parts a. Place towel of waterproof pads under and reduces patient’s anxiety. body part to be shaved. b. Drape the patient with blanket, leaving only area to be shaved at one time (10 Provides maximum skin illumination. to 20 cm [4 to 8 inches]) exposed. Softens hair and reduces friction from razor. c. Adjust lamp. d. Lather the public hair (if it is to be Shaving small areas minimizes cutting skin; removed) dipped in antiseptic soap. shaving in direction hair grows prevents e. Shave small area at a time. With non- pulling. dominant hand hold gauze sponges to stabilize skin. Hold razor at 30/40- degree angle in dominant hand. Begin at the pubis and shave toward the perineum. Be sure to remove all hairs from the labia and cleanse away the collection of smegma (cellular debris found especially in the labial folds). Shave hair in direction it grows. Use The “true perineum” is the area cut during the short, gentle strokes (see illustration). episiotomy. Avoid getting any solution into the vagina. Be sure that the “true perineum” Maintains clean, sharp razor edge to promote is well shaved and clean. client’s comfort and reduces risk of cuts and f. Rinse razor in basin of water as soap abrasions. and hair accumulate on blade. Change  and discard blades as they become dull. Maintains client’s comfort and privacy. g. Rearrange bath blanket as each potion of shave is completed. Reduces skin irritation and potential h. Use washcloth and warm water to rinse contamination; allows good visualization of away remaining cut hair and soap skin. solution. Change water as needed. Reduces maceration of skin from retained i. Dry shaved areas with towel, and dry moisture. crevices with dry cotton-ripped applications or cotton balls. Reduces spread of microorganisms. j. Discard waterproof towel or pad. Any break in skin integrity increases risk of k. Observe skin closely for any nicks or wound infection. cuts. Relieves client’s anxiety. 7. Tell client when procedure is completed. Reduces spread of infection and reduces risk 8. Clean with soap and water and dispose of injury from contaminated razor blades. equipment according to policy. Do not Occupational Safety and Health recover razor blade. Razor handle with Administration (OSHA) guidelines requires blade is discarded into contaminated sharps gloves to be worn, razor blades to be disposed holder. Dispose of gloves. of safety, and reusable items to be sterilized. 9. Wash hands. Reduces spread of microorganisms. EVALUATION Determines if there is remaining hair of skin or 1. Inspect condition of skin after completion of if skin was cut. hair removal. 2. Question if patient feels burning, Indicates presence of skin cut, irritation or discomfort, or itching. allergic response. RECORDING AND REPORTING 1. Record procedure, area clipped or shaved, and condition of skin before and after in nurse’s notes. 2. Report any skin alterations, nicks, or cuts in skin to surgeon. Skin problems may require cancellation of surgery. UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS  Patient’s skin is not totally clear of all hair.  Exceptionally thick hair is difficult to remove the first time. Additional depilatory or another shave is necessary.  Patient’s skin becomes but, nicked, or inflamed.  Blade may be dulled, angle of blade was not correct, or too much pressure was applied. Even minor skin wounds can become infected. Notify surgeon. NOTE:  Have you first “Prep” checked so that you are certain what is expected of you. Even if it is your first “prep”, you should not impress the fact on your anxious patient.  During the prep, if possible, try to gauge the frequency and quality of any contractions the patient may have, as well as how she is tolerating them. Report any vaginal discharge as to character and amount.  No perineal pads are worn during labor to cut down on the possibility of vulvar contamination resulting from the pad passing from the rectal to the vaginal area. However, the patient may have absorbent, protective bed pads under her hips.  COLLEGE OF NURSING Silliman University Dumaguete City PERINEAL SHAVE Student: _________________________________ Instructor: _______________________________ Instructor’s Signature: ____________________ Date: _______________ PERFORMANCE CHECKLIST PERINEAL SHAVE ASSESSMENT 1 2 3 4 1. Check physician’s order or institution’s procedure for shaving perineum 2. Inspect general condition. 3. Assess for allergy to iodine or shellfish. 4. Assess for bleeding tendency by reviewing patient’s medications history, and coagulation laboratory values (prothrombin time [PT]), partial thromboplastin time [PTT]). 5. Assess patient’s understanding and acceptance of purpose for hair removal. NURSING DIAGNOSIS Develops appropriate nursing diagnosis based on assessment data. PLANNING 1. Identify expected outcomes following completion of procedure:  Patient’s skin is free of all hair over perineal area.  Skin is free of visible cuts, nicks, and areas of inflammation.  Patient denies burning, discomfort, or itching. 2. Wash hands. 3. Prepare equipment at patient’s bedside. 4. Explain procedure, extent of hair removal, and rationale for removal of hair. IMPLEMENTATION 1. Identify patient. 2. Provide privacy. 3. Position patient comfortably. 4. If possible, place the light (wall or gooseneck lamp) on opposite of bed from where a nurse stands. 5. Apply disposable gloves. 6. Wet shave: a. Place towel or waterproof pads under body part to be shaved. b. Drape the patient with bath blanket, leaving only area to be shaved at one time (10 to 20 cm or 4 to 8 inches) exposed. c. Adjust lamp. d. Lather the pubic hair (if it is to be removed) using sponge or cotton balls dipped in antiseptic soap. e. Shave small area at a time correctly. f. Rinse razor in basin of water as soap and hair accumulate on blade. Changes and discards blades as they become dull. g. Rearrange bath blanket as each portion shaved is completed. h. Use washcloth and warm water to rinse away remaining cut hair and soap solution. Changes water as needed. i. Dry shaved areas with towel and dry crevices with dry cotton-ripped applicators or cotton balls. j. Discard waterproof towels or pad. k. Observe skin closely of any nicks or cuts. 8. Make patient comfortable. 9. Clean equipment with soap and water. Discard razor handle with blade into contaminated sharps holder. (Follow institution’s policy). 10. Dispose gloves properly. 11. Wash hands. EVALUATION 1. Inspect condition of skin after completion of hair removal. 2. Assess if patient feels burning sensation, discomfort, or itching. RECORDING AND REPORTING 1. Record procedure, the area clipped or shaved, and condition of skin before and after in nurse’s notes. 2. Report any skin alterations, nicks, or cuts in skin to surgeon. Skin problems may require cancellation of surgery.