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MEDICAL AND SURGICAL PROCEDURE MANUAL

CARING FOR A CLIENT’S UNIT

I. Definition

Environment- the sum total of the external surroundings and influences

Client’s Unit- a space or room consisting of a bed, mattress, mattress cover, pillow, bedside
table, chair, utensils, and other equipment which are prepared for client’s use while staying
in the facility.

Therapeutic environment- an environment which helps the client grow, learn, and return to
health

Care of Client’s Environment- the process of preparing the client’s unit for admission,
maintaining its cleanliness while the client is in the healthcare facility, and cleaning the unit
after the client has been discharged.

II. Rationale

1. To provide the client with the necessary space and articles needed for his or her
recovery.
2. To provide an atmosphere that simulates home and eventually giving emotional
satisfaction to the client.
3. To attend to the safety, security, and hygiene needs of the client.

III. Guideline (ActionsRationale)

A. For Admission
1. Check if the client’s room is newly cleaned. Furniture should be free from dust.
 To remove possible sources of infection.
2. Adjust air conditioning units to desired coolness.
 Promote client’s comfort
3. Use new set of clean linens
 To make the bed ready for client’s admission
4. Adjust artificial lighting depending on the time when the client comes in
 To enhance therapeutic effect of environment
5. Check if the comfort room has been properly cleaned, disinfected and provided with
necessary articles.
 To promote hygiene and sanitation
6. Leave the unit untouched until the client is admitted. Minimize entry of personnel
 To prevent possible contamination
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B. After the Client’s Discharged

1. Strip the bed and discard the linens on the hamper and send to the laundry
department. Expose mattress and pillows to sunlight. Remove drapes.
 Linens are considered soiled once the client is discharged from the unit.
 Exposure to sunlight is a way to disinfecting pillows and mattresses.
2. Sweep the floor thoroughly. Using the floor mop wet with a disinfectant, wipe the
floor thoroughly. Allow the floor to dry.
 To disinfect the floor while eliminating microorganisms
3. Wipe furniture with a dust cloth wet with appropriate disinfectant
 To disinfect the furniture
4. Do general cleaning of bath and comfort rooms.
 To prevent contamination.
5. Dispose the garbage properly
 To prevent contamination
6. Use air disinfectant/ freshener as necessary.
 To freshen and disinfect the air.
7. Turn off lights and air conditioning units.
 To avoid power wastage.

Note: Cleaning tasks can be delegated to the janitor.

IV. Evaluation
1. Cleanliness and tidiness of the unit.
2. Aesthetic appearance of the unit
3. Hygiene and Sanitation of the unit
4. Overall Therapeutic effect of the unit on the client
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MAKING A BED FOR A CLIENT

I. Definition

 Bedmaking –a procedure wherein bed linens are changed to make the client comfortable
during the entire stay in the healthcare facility.
 Surgical Bed –a bed made for a client who is undergoing a surgical or diagnostic
procedure that requires the use of an anesthetic agent
 Stripping the Bed –is a procedure wherein used linens are removed from the bed and the
bed mattress is aired.

II. Rationale
1. To provide comfort and safety
2. To provide a clean bed for the client
3. To make a bed that is comfortable and neat while being occupied by a client.
4. To help maintain proper body alignment

III. Planning and Implementation

Special Considerations:
A. Asepsis in Bedmaking
1. Handle linens carefully. Avoid shaking them. Place soiled linens inside the
laundry hamper and not on the floor.
 To prevent the spread of microorganisms which move through space in air
currents. The floor is the most contaminated area.
2. Hold both soiled and clean linens away from your uniform.
 To prevent contamination. Microorganisms are transferred from one surface to
another whenever one object touches another.
3. Wash hands before and after the procedure.
 To prevent the spread of the microorganisms.

B. Body Mechanics in Bedmaking

1. Raise the bed to a comfortable height. Bend your knees and notb your back.
 To prevent fatigue. A person or an object is more stable if the center of gravity
is close to the base of support.
2. See to it that the entire body is facing in the direction that you are moving and
avoid twisting the body.
 To lessen the susceptibility of the back to injury
3. Make the bed completely on one side before moving to the other side. Organize
your work and move with moderate speed.
 To save time and effort.
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STRIPPING THE BED

1. Wash hands.
 To prevent spread of microorganisms
2. Obtain a laundry or hamper bag.
 To be used for soiled linens.
3. Place the chair at the foot part of the bed.
 To be used for the pillow after removing the pillowcase.
4. Remove the pillowcase from pillow. Place the pillow on chair and soiled pillowcase on the low bar
of the bed or in the hamper.
 To limit transfer of microorganisms.
5. Check bed linens for any of the client’s misplaced personal items.
 Prevent losses of client’s personal items.
6. Loosen the top and the bottom linen from the matress, moving around the bed from head to foot on
one side and foot to head to the opposite side.
 To prevent stretching and reaching and possible muscle strain.
7. Roll all soiled linen inside the bottom sheet while holding away from your uniform. Place it
directly in the hamper.
 Prevents transfer of microorganisms
8. Remove the mattress cover, discard it into the hamper and turn the mattress cover.
 To allow the mattress to be expose to sunlight and air.
9. Do aftercare and wash your hands.
 To prevent the spread of microorganism.
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ADMITTING A CLIENT

I. Definition

Admitting a Client –a process of getting a client signed into the healthcare facility

II. Rationale
1. To provide a comfortable and aesthetically pleasing environment to the client.
2. Maintain asepsis by preventing spread of microorganisms.
3. Provide the client some control over the client’s immediate environment.
4. To provide the client with an opportunity to verbalize his or her feelings about admission.
5. To encourage the client to participate in his or her plan of care.

III. Planning and Implementation

1. Immediate Needs of the Person –should be the first concern
a. Physical Needs –if the client is in pain, institute nursing measure to relieve pain and contact
physician immediately.
b. Emotional Needs –if the client is upset, spend time listening and talking to the client. This
can facilitate the transition to the healthcare environment.
2. Introduction and Orientation –greet the client, introduce yourself and call the client by his or
her name. Orient the client to the unit. This relieves the anxiety related for the fear of the
unknown.
3. Baseline Assessment –information to be gathered
A. Admission and Discharge Record
B. Admitting History (Chief Complain, History of Present Illness, Past Medical History,
Review of Drug Allergies)
C. TPR, BP, weight, RBS
D. Physical Examination ( Operative Site)
E. ECG
4. Obtain consent for treatment –ensures medico-legal aspect of surgical procedure
5. Care of Belongings and Personal Property –protection of the patient’s belongings to safe-
keeping
6. Record Keeping –recording all parts of the admission process is essential for legal records.
7. Ensure complete Philhealth requirements –for Philhealth Beneficiaries and members acquiring
the facility’s surgical services.

IV. Documentation and Evaluation

1. Time, Date, and Client’s Status upon admission.
2. Medical, Surgical and Nursing Care rendered.
3. Procedures done properly.
4. Client’s status after all necessary care and tests were done.
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DISCHARGING A CLIENT

I. Definition

Discharge Planning –a systematic process for preparing a client to leave the healthcare agency and
for continuity of care.

II. Rationale
1. To prepare the client for leaving the healthcare agency.
2. To transfer a client whose condition necessitates care in some other healthcare facility.
3. To provide an environment, either home or another community agency or facility that best
meets the needs of the client.
4. To allow the client to verbalize his or her feelings about discharge and identify the client’s
strength and weaknesses.
5. To help the client become aware of potential changes in the environment and lifestyle due to
his or her disability or limitation.

III. Planning and Implementation

1. Check to see that the proper form has been completed.
 This is a must before discharging the client as this is the responsibility of the
physician to give the discharge order.
2. Check if the client or a family member or a relative has been given discharge instructions such
as medication, follow-up check-up, treatment at home, wound dressing, removal of sutures,
etc.
 Pre-discharge instructions are necessary for the full recovery of the client.
3. Check to see that proper financial arrangements have been made by the client or family
member (for NPhiC patients availing Pay Package of Surgical Procedures)
 To avoid legal financial problems.
4. See to it that all of the client’s belongings are given to him or her.
 To avoid loss of belongings and further problems in the future.
5. Assist the client as necessary for his or her transport.
 To ensure safety and responsibility towards client’s welfare.

IV. Evaluation and Documentation

1. Pre-discharge health teaching given.
2. Medical, surgical, and nursing care rendered before discharged.
3. Date, Time, and Status of the client upon discharge.
4. Accompanying person and mode of transportation upon discharge.
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PREPARING CLIENT FOR AN ELECTROCARDIOGRAM (ECG/EKG)

I. Definition

ECG –records the electrical activity generated in the heart during the cardiac cycle.

II. Rationale
1. To provide grounds for the diagnosis of cardiac arrhythmias, arteriosclerotic heart
disease, cardiac enlargement, electrolyte abnormalities and myocardial infarction.
2. To assess the status of a client in a life threatening situation as a basis for medical or
nursing action.
3. To provide a visual image of the heart’s rhythm.

III. Planning and Implementation

1. Elicit and record the client’s age, sex, weight, blood pressure, symptoms and medications; unusual
position of the client during examination; and the presence of thoracic deformities, amputation,
respiratory distress or muscle tremors.
 Facilitates interpretation of the ECG
2. Ask the client if he or she has ever had an ECG before. Explain that the procedure will take only 10-15
minutes and is painless.
 Simple explanation reduces the client’s anxiety.
3. Assist the client to assume a supine position.
 Facilitates good recording
4. Close the door and bedside curtains
 Provides privacy for the client
5. Secure electrodes on the flat inner aspects of the client’s wrists and ankles with extremity straps
adjusted to hold the electrodes firmly in place. Use KY Jelly as necessary.
 If the straps are placed too tightly, circulation to the extremity could be
compromised. Use of KY Jelly ensures good contact between the client’s skin
and the electrodes.
6. Attach the chest leads
 The recording will vary according to the placement of the leads.
a. V1 –at the 4th intercostal space, at the right sternal border
b. V2 –at the 4th intercostal space, at the left sternal border
c. V3 –at the midpoint between V2 and V4
d. V4 –at the 5th intercostal space at the Mid-clavicular Line
e. V5 –at the level of V4, at the Left Anterior Axillary Line
f. V6 –at the level of V4, at the Left Mid-Axillary Line
7. Turn on the LEAD selection switch to record all 12 Leads
8. Remove the Leads and any paste that may be remaining.
 Promotes the client’s comfort
9. Place the ECG result on the chart and note the time and condition of the client
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 Communicates to the other members of the healthcare team and contributes to

the legal record by documenting the care given to the client.

IV. Evaluation

A visual representation of the electrical conduction pattern of the client’s heart is

reflected by changes in electrical potential at the skin surface.
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HANDWASHING (MEDICAL ASEPSIS)

I. Definition

Handwashing –is a procedure wherein thorough cleaning of the hand using a soap is done by
rubbing briskly on a rotary motion.

Medical Asepsis –is the practice of techniques and procedures designed to reduce the number of
microorganisms in an area or an object and to decrease the likelihood of their transfer.

II. Rationale
1. To help prevent the spread of pathologic microorganisms
2. To reduce the number of microorganisms
3. To deliver client care with pathogen-free hands
4. To protect clients from cross-contamination
5. To protect the healthcare provider as well as the client

III. Planning and Implementation

1. Remove your watch, roll your sleeves above elbows.
 To allow you to wash your hands well.
2. Turn on the water and adjust the temperature if adjustment is available.
 Warm water removes fewer oils from the skin than hot water, and removes
microorganisms more effectively than cold water.
3. Dispose of the liquid or liquid soap.
 Bar soaps may harbor microorganisms.
4. Lather your hands and arms well.
5. Clean your fingernails as needed with nail file.
 The sub-fingertips has been shown to be especially important, as it is an area
where bacteria multiply, but this is frequently missed in hand washing.
6. Wash your hands and arms to your elbows adding soap as needed. Keep your hands lower than
your elbows at all times.
 To maintain a lather. Microorganisms are suspended in the lather and lather
rinsed off.
a. Rub briskly using friction and a rotary motion
to contact all surfaces more effectively
b. Pay particular attention to the areas between your fingers, knuckles, and the
outside surfaces of the fifth or little fingers.
this areas are often missed
7. Hold your hands and forearms lower than your elbows, rinse thoroughly, starting at one elbow
and moving down the arm. Then repeat this step for the other arm.
 This position prevents microorganisms from being rinsed up your arms from
your hands, which are frequently the most contaminated.
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8. Dry your hands thoroughly with a hand towel, blotting it and not rubbing it.
 Blotting is gentler on the skin than rubbing that can cause abrasion and
chapping.
9. Use a dry hand towel to turn off the faucet if it is hand operated
 To avoid recontaminating your hand since a dirty hand was used to turn it on.

IV. Evaluation
1. Reduces the number of microorganisms on the hands.
2. Reduces the risks of transmission of the microorganisms to the client.
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DRESSING A WOUND

I. Definition

Wound Dressing –a technique of aseptically dressing a wound that involves placing a protective
covering over a wound.

II. Rationale

1. To protect the wound to prevent further trauma

2. To provide pressure on a wound
3. To help immobilize and support the injured area
4. To help keep the wound free of drainage and debris

III. Planning and Implementation

1. Assess the size and location of the wound.
 If the wound is draining excessively, additional supplies may be needed.
2. Tell the client what to expect
 Simple explanations help reduce anxiety and apprehension
3. Help the client assume a comfortable position so that the wound is easily accessible.
 Facilitates cleansing of the wound.
4. Expose the wound area and drape the client with a sheet.
 Provides access to the wound area and privacy for the client.
5. Set up a water-proof disposable bag in a convenient location.
 Water-proof bag prevents leaking of wound drainage
6. Remove the dressing and tape if present. Grasp the edge of the tape, hold the client’s skin
proximal to the edge of the tape and gently pull the tape toward the wound.
 Providing counteraction of the skin as the tape is removed, reduces discomfort
and promotes skin integrity.
7. Don examination gloves.
 Gloves protect you from the microorganisms in the wound dressing.
8. Lift the dressing and tape, if present.
 The appearance of the dressing maybe distressing to the client.
9. Dispose the tape and dressing in a water-proof bag. Remove the disposable gloves inside-out
and place them in a waterproof bag. Wash your hands.
10. Set-up a sterile field on the overbed table. Open all packages of sterile supplies and aseptically
place them on the sterile field.
 Decreases the transmission of microorganisms
11. Using sterile forceps, pick-up a 4 x 4 gauze pad and saturate it with cleansing solution.
 Use of sterile pick-up forceps lessens the chance of contamination as you clean
the wound.
12. Cleanse the wound with one stroke at a time from the cleanest to the least clean area.
 The wound itself is considered to be the cleanest area.
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13. Drop the used gauze pad into the bag without touching the inside of the bag with your hand or
forceps.
 The inside of the bag is considered to be contaminated.
14. Dry the wound area with the dry gauze pads. Use the same one-stroke action.
 Excessive moisture on the skin promotes the growth of microorganisms.
15. Apply a dressing
 Moisture on the wound and skin promotes growth of microorganisms.
16. Dispose of the soiled supplies in a bag.
 Prevents transmission of microorganisms and prevents odors.
17. Wash your hands.
 Decrease transmission of microorganisms.
18. Record the procedure. Note your observations of the site.
 Communicates the findings to the other members of the healthcare team and
contributes to the legal records by documenting the care given to the client.

IV. Evaluation
1. There are no signs of infection
2. The tissue around the client’s wound is not inflamed and there are no signs of infection
3. There is no wound drainage
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PERFORMING PRE-OPERATIVE SKIN PREPARATION

I. Definition

Skin Preparation –a procedure which renders the skin at and around the surgical site, scrupulously
clean and free of hair which reduces the chance of introducing organisms into the surgical wound.
II. Rationale
1. To remove the hair from a defined skin area
2. To clean the area, thus reducing the number of microorganisms present, which could cause
post-operative wound infection

III. Planning and Implementation

1. Wash hands before the procedure
 Reduce the number of the microorganisms present.
2. Explain the procedure to the client
 To allay fear and anxiety
3. Eliminate draft
 To prevent client from chilling
4. Provide a good light
 To see hair on the skin
5. Drape client properly exposing only the area to be prepared.
6. Check any special order by the surgeon about skin preparation
7. Check procedure manual for skin area to be prepared for the surgery.
8. Lather the skin with soap solution
 To moisten the skin and facilitate easy movement of the razor by lessening
friction
9. Stretch the skin taut and hold the razor for 45 ° angle to the skin. Move the razor along the root
of the hair when starting the procedure especially on areas with plenty of hair; but move the
razor against the root of the hair in the last cleaning stroke.
 Moving the razor on the direction of the hair growth eliminates pain. Short
remaining hairs can easily be removed by moving the razor against the root.
10. Wipe excess hair of the site with sponges.
11. Cover with sterile towel the prepared area. Hold in place using the adhesive tapes.
 To prevent the prepared area for contamination of all source.

IV. Evaluation

The operation site and surrounded areas are clean.

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DONNING AND REMOVING STERILE GLOVES (OPEN METHOD)

I. Definition

Gloves –latex or vinyl gloves use anytime a sterile procedure is conducted.

II. Rationale
1. To enable the nurse to handle sterile objects freely
2. To prevent clients at risk (those with open wounds ) from becoming infected by
microorganisms on the nurse’s hands.

III. Planning and Implementation

1. Determine if sterile gloving is necessary
 Sterile gloving is not necessary for every procedure. It may be safe for the client
and cost-effective to use disposable nonsterile gloves.
2. Thoroughly wash your hands
 Decreases the transmission of microorganisms
3. Explain to the client that sterile gloving is necessary for protection against infection.
 Explanations helps reduced a client’s apprehension
4. Place the unopened package of gloves on a clean and dry surface.
 If the package becomes wet, it is no longer considered sterile.
5. Open the outside paper covering the sterile gloves by grasping the tabs on top of the
package and peeling the paper open.
 Avoid contamination of the sterile gloves.
6. Remove the outer wrapper and lay the exposed package of gloves on a clean, dry
surface.
 Provides easy access to the gloves
7. Open the inner package containng the sterile gloves by touching only the bottom of
the package.
 Avoid contamination of the sterile gloves inside the wrapper.
8. With the thumb and finger of one hand, grasp the cuff portion of the opposite glove
and lift the glove while holding your fingers down.
 Contaminates only the inside of one glove
9. Slide the glove into your hand, taking care not to touch any portion of the gloves
except the cuff portion.
 Avoids contamination of the outside of the glove. Your hand and the inside of
the gloves are not sterile.
10. Using your gloved hand, slide your fingers under the cuff portion of the other glove.
 Avoids contamination of the second glove. Your gloved hand and the outside of
the glove are sterile.
11. Slide the second glove on your hand without touching your skin.
 Maintains sterility of the glove. Your skin is not sterile.
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12. Turn the cuff of the second glove into your wrist without touching the inside of the
cuff.
 Maintains sterility of the gloves. The iside portion is not sterile.
13. Turn the cuff up on the other hand, taking care not to touch the inside of the cuff.
 The inside part of the cuff is contaminated.

REMOVING OF SOILED GLOVES

14. Grasp the outside of one glove and pull it off inside-out.
 Prevents your hands from coming in contact with the outside contaminated
portion.
15. Slide your fingers under the remaining gloved hand and remove the glove inside-
out.
 You avoid touching the contaminated outside surface of the second glove and
decrease the transmission of microorganisms.
16. Dispose the gloves in proper receptacle.
17. Wash your hands.
 Decreases the transmission of microorganisms.

IV. Evaluation

The client is not introduced to any microorganisms and does not develop a
nosocomial infection.