NGT Insertion Complications:

Bleeding
Learning Objectives Pneumothorax
1. Describe principles related to the Aspiration
function NGT insertion. Intracranial placement
2. Determine the factors that affect the Vomiting/retching
flow of fluid through the NG tube Pulmonary placement
3. Explain the guidelines for working with Sinusitis
patients with NGT in situ
4. Discuss the purposes, types, special Equipment:
precautions, potential complications,  Nasogastric tube (fine bore)
and interventions for NGT insertion  Disposable gloves
 Lubricant and gauze
Introduction  Disposable bowl
 Paper Towels
Patients in the Emergency room, Acute  Large Syringe
care and in the Community settings often  Dressing
have a Nasogastric tube insertion to assists  A glass of water for the patient (if
in an emergency situation, in a recovery swallow is deemed safe).
from surgeries, medical conditions, or  Local anesthetic spray
diagnostic procedures.

We Nurses, must comprehend how these

devices work, their purpose, function,
insertion, removal and how to prevent
complications from these procedures.
Nasogastric Tube Placement
Indications
o -Decompression of stomach
(e.g. obstruction
perforation)
o -Reduce incidence and risk of
vomiting
o -Monitor and evaluate upper
gastrointestinal bleeding
o -Prolonged ileus
o -Administration of medication
or oral contrast in a patient
unable to swallow
o -Detection of trans
diaphragmatic stomach
herniation
Parenteral Nutrition
Infusion of nutrients directly into a vein who
are unable to eat or digest food through the
GI tract, who refuses to eat, or who have
inadequate oral intake
METHODS:
or 1. TOTAL PARENTERAL NUTRITION
2. PARTIAL PARENTERAL NUTRITION
PURPOSE
 To provide nutrients required for
normal metabolism, tissue
maintenance, repair and energy
demands.
 To bypass the GI for patients who are
unable to take food orally.
 To rest the GI tract
INDICATION:

Nasogastric Tube Placement 1. Patient who cannot tolerate enteral

nutrition because of:
Contraindications  Paralytic ileus
o -Midface injury, basilar skull  Intestinal obstruction
fracture, or coagulopathy  Acute pancreatitis
(Orogastric placement may be  Inflammatory bowel disease
a better option)  Gastrointestinal fistula
o -History of gastric bypass or lap  Severe diarrhea
banding  Persistent vomiting
o -Esophageal structures or alkali  Malabsorption
injury
2. Patient at risk for malnutrition
 Gross under weight
  Metastatic cancer

3. Hypermetabolic state (w/c enteral

feeding is not possible)
 Severe burns
 NPO for more than 5 days
 ARF
 Multiple fracture
 Tumor in the GIT
 Infection with fever

METHODS OF PARENTERAL NUTRITION

Total parenteral Nutrition (TPN)

TPN ADMINISTRATION BAG

ADMINISTRATION SET WITH LEUER LOCK

SYSTEM
NURSING CARE PLANS
 Imbalanced Nutrition: Less Than Body
Requirements
 Risk for Excess Fluid Volume
 Risk for Deficient Fluid Volume

Assisting a Client with Assistive Devices

Objectives:

At the end of the lecture the student will be

able to:
 Purpose of assistive devices.
 State the indications for ambulating
with assistive devices.
 Define what is cane.
 State the purpose of using a cane.
 Describe the three types of canes.
 Name the basic parts of a cane.
 Describe three characteristics of
appropriately fitted cane.
 Identify appropriate assessment skills
prior to the procedure.
 Formulate relevant nursing diagnosis
related to the procedure/ treatment/
therapy.
 Demonstrate the step-by-step
procedure: Assisting a Patient with
Ambulation Using a Cane, stating the
rationale for each steps.
 Describe “moving in and out” of a
chair using a cane.
 Discuss the “going up and down” the
stair using a cane.

Indication for Assistive Devices

 Structural deformity,
 Amputation,
 Injury, or disease resulting in
decreased ability to weight bear
through lower extremities
 Muscle weakness or paralysis of the
trunk or lower extremities
  Inadequate balance  Check your wrist height.
cane tip about 3-4” from the
foot and at a 450 angle

Canes
are assistive devices, useful for patients who
can bear weight but need support for
balance and stability.

 useful for patients who have

decreased strength in one leg.
 provide an additional point of
support during ambulation and
promotes greater independence.
 are made of wood or metal and
often have a rubberized cap on the
tip to prevent slipping. Canes come
I: ASSISTING A PATIENT WITH AMBULATION
in three variations:
USING A CANE
Types of Cane
Equipment:
 Cane of appropriate size with rubber
tip
 Nonskid shoes or slippers
 Nonsterile gloves and/or other PPE, as
indicated
 Stand-assist aid, if necessary and
available
 Gait belt, based on assessment

Parts of A Cane
 Handle
 Collar
 Shaft
 Ferrule

ASSESSMENT:
 Assess the patient’s upper body
strength, ability to bear weight and to
walk, and the need for assistance.
 Review the patient’s record for
Fitting the Cane conditions that may affect
ambulation.
Make sure your cane fits the patient  Perform a pain assessment before the
properly: time for the activity.
 Check your elbow bend.
  If the patient reports pain, administer
the prescribed medication in
sufficient time to allow for the full
effect of the analgesic.
 Take vital signs and assess the patient
for dizziness or light headedness with
position changes.
 Assess the patient’s knowledge
regarding the use of a cane.

NURSING DIAGNOSIS:
 Activity Intolerance
 Impaired Walking
 Acute Pain
 Deficient Knowledge
 Chronic Pain
 Risk for Injury

OUTCOME AND PLANNING:

 The expected outcome to achieve
when assisting a patient with
ambulation using a cane is that the
patient ambulates safely without falls
or injury. Additional appropriate
outcomes include the following:
 the patient demonstrates proper use
of the cane; the patient
demonstrates increased muscle
strength, joint mobility, and
independence;
 the patient exhibits no evidence of
injury from use of the cane.
Goal: The patient ambulates safely without falls or injury.
STEP
1. Review the medical record and nursing
plan of care for conditions that may
influence the patient’s ability to move
and ambulate. Assess for tubes, IV
lines, incisions, or equipment that may
alter the procedure for ambulation.
2. Perform hand hygiene. Put on PPE, as
indicated.
3. Identify the patient. Explain the procedure
to the patient. Help the patient
familiarize with the parts and use of the
cane. Tell the patient to report any
feelings of dizziness, weakness, or
shortness of breath while walking.
Decide how far to walk.
4. Assist the patient to put on appropriate
socks and shoes.
5. Encourage the patient to make use of a
stand-assist aid, either free-standing or
attached to the side of the bed, if
available, to move to and sit on the
side of the bed.
6. Wrap the gait belt around the patient’s
waist, based on assessed need and
facility policy.
7. Encourage the patient to make use of the
stand-assist device to stand with
weight evenly distributed between the
feet and the cane.
8. Have the patient hold the cane on his or
her stronger side, close to the body,
while the nurse stands to the side and
slightly behind the patient.
9. Ensure appropriate fitting of the cane.
(see fig. 3)
Check the patient’s elbow bend.
Check the patient’s wrist height.
10. Tell the patient to advance the cane 4 to
12 inches (10 to 30 cm) and then, while
supporting his or her weight on the
stronger leg and the cane, advance
RATIONALE
Review of the medical record and plan of
care validates the correct patient and
correct procedure. Identification of
equipment and limitations helps
reduce the risk for injury.
Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based
on transmission precautions.
Patient identification validates the correct
patient and correct procedure.
Discussion and explanation help allay
anxiety and prepare the patient for
what to expect.
Non slip-rubberized sole shoes helps provide
steadier balance.
Encourages independence, reduces strain
for staff, and decreases risk for patient
injury.
Gait belts improve the caregiver’s grasp,
reducing the risk of musculoskeletal
injuries to staff and the patient and
provide firmer grasp for the caregiver
if patient should lose his or her
balance.
A stand-assist device reduces strain for
caregiver and decreases risk for
patient injury. Evenly distributed
weight provides a broad base of
support and balance.
Holding the cane on the stronger side helps
to distribute the patient’s weight away
from the involved side and prevents
leaning. Positioning to the side and
slightly behind the patient encourages
the patient to stand and walk erect. It
also places the nurse in a safe position
if the patient should lose his or her
balance or begin to fall.
This manner provides support and balance.
Cane that is too long makes it harder to pick
it up and move it. or too short cane can
throw the patient off balance.
Moving in this manner provides support and
balance.
 the weaker foot forward, parallel with
the cane.

11. While supporting his or her weight on the Moving in this manner provides support and
weaker leg and the cane, have the patient balance.
advance the stronger leg forward ahead of
the cane (heel slightly beyond the tip of the
cane).

12. Tell the patient to move the weaker leg This motion provides support and balance.
forward until it is even with the stronger leg,
and then advance the cane again.

13. Continue with ambulation for the planned Continued ambulation promotes activity.
distance and time. Adhering to the planned distance and
patient’s tolerance prevents the patient from
becoming fatigued.

14. Return the patient to the bed or chair Balance activity and rest prevents fatigue
based on the patient’s tolerance and and ensures the patient’s comfort.
condition. Make sure call bell and other
necessary items are within easy reach.
15. Clean transfer aids per facility
policy, if not indicated for single patient
use. Remove PPE, if used. Perform hand
hygiene.
Proper cleaning of equipment between patient
use prevents the spread of microorganisms.
Removing PPE properly reduces the risk for
infection transmission and contamination of other
items. Hand hygiene prevents the spread of
microorganisms.

EVALUATION:

16. Evaluate Determines if the expected outcome is met or not,

thus needs to be changed.
A. if the patient uses the cane to
ambulate safely and is free from
falls or injury.
B. the patient demonstrates proper
use of the cane;
C. the patient exhibits increased
muscle strength, joint mobility,
and independence; and
D. the patient experiences no injury
related to cane use.

17. Document: Provides information with regards to patient’s

progress to care and response to therapy.
A. the activity, any other pertinent
observations,
B. the patient’s ability to use the
cane,
C. the patient’s tolerance of the
procedure, and the distance
walked.
D. the use of transfer aids and the
number of staff required for
transfer.
  May cause armpit injury, known as
Crutch crutch paralysis, or crutch palsy.

-is a mobility aid that transfers weight from

the legs to the upper body. It is often used
by people who cannot use their legs to
support their weight, for reasons ranging
from short-term injuries to lifelong disabilities.

Prerequisites for Crutches

 Good strength of upper limb muscles
is required.
 Range of motion of upper limb should
be good.
 Shoulder adductors
 Elbow and wrist extensors
 Finger Flexors

Types of Crutches
2. Forearm or Lofstrand Crutches
1. Underarm or axilla crutches
A forearm crutch also commonly
Underarm crutches are used by
known as an elbow crutch, Canadian
placing the pad against the ribcage
crutch or "Lofstrand" crutch, it has a cuff at
beneath the armpit and holding the grip,
the top that goes around the forearm. It is
which is below and parallel to the pad. They
used by inserting the arm into a cuff and
are usually used for short term injuries to
holding the grip. The hinged cuff, most
provide support for patients who have
frequently made of plastic or metal, can be
temporary restriction on ambulation.
a half-circle or a full circle with a V-type
opening in the front allowing the forearm to
Advantages:
slip out in case of a fall. Used by users with
 Underarm crutches are adjustable to
long term disabilities.
a person’s height and comes with
arm pads and handgrips for comfort.
Advantages:
It allows patient to perform a greater
 Encourage the user to use good
variety of gait patterns. It is also
posture, and experience less back
available at low cost.
and neck problems.
 Increase your upper body strength
Disadvantages:
over time.
 This type of crutch people tends to
 Reduce strain and keep pressure off
slouch while using them.
your wrist while moving.

Disadvantages:
 Hard to use for beginners.

3. Platform or Gutter Crutches

These are less common and used by
those with poor hand or grip strength. These
types of crutches, is composed of padded
forearm support made up of metal, a strap
and adjustable hand piece with a rubber
ferrule.
4. Leg Support
These non-traditional crutches are
useful for users with an injury or disability
affecting one lower leg only. They function
by strapping the affected leg into a support
frame that simultaneously holds the lower
leg clear of the ground while transferring
the load from the ground to the user's knee
or thigh.
GAIT TRAINING: Principles
Gait- A pattern of walking or a sequence of
foot movements.
Weight Bearing is the amount of
weight that may be borne on a lower
extremity during standing or ambulation. It
is determined by patient’s condition and
medical management of that condition.
Changes in weight bearing status are
determined by the patient’s physician.
Types of Weight Bearing
1. None Weight Bearing: involved lower
extremity not to bear weight or
touching floor.
2. Toe Touch Weight Bearing: patient
can rest toes on the floor for balance,
but not to bear weight.
3. Partial Weight Bearing: limited
amount of weight bearing permitted
on lower.
4. Weight-Bearing as Tolerated: patient
allowed to place as much or as little
weight through the involved lower
extremity, depending on patient’s
tolerance.
5. Full Weight-Bearing: The leg can now
carry 100% of the body weight, which
permits normal walking.
Standing with Crutches
Tripod Stance is what provides
your body with the most
support and keeps weight off
of your injured leg when standing
still. Keep good foot firmly on
the ground and place the crutches
in front, crutch tip 6” from the foot
and at a 45-degree angle.
Measuring for the Crutches
Standard axillary crutches need two
adjustments-the length of the crutch and
the position of the handgrip. Prior to
adjusting, prepare the crutches with
padding on the axillary bar and a rubber tip
on the end of each crutch.
Lying:
 Have the patient lie supine, arms at
sides, wearing a shoe on the
unaffected foot.
 Using a tape measure, measure from
the axilla to the heel of the shoe and
add two (2) inches. Adjust the crutch
shaft to this measurement.
Standing:
 Crutch tip 6” from the foot and @ a 45
angle
 Hand grip @ the ulnar styloid process
or
 Hand grip @ the level of the greater
trochanter
 Elbow in about 15-30 degrees of
flexion
 Axillary distance to the top of the
crutch, 2-3 finger widths
Gait Patterns
Two-point gait:
-the client is partially weight-bearing
on both legs. (A crutch and the opposite
leg are considered one “point.” The other
crutch and leg are the second “point.”)
Gait speed is faster than 4 point, but less
stable as only two points are in contact with
floor and good balance is needed to walk
with 2 points crutch gait. Low energy
required by patient.
 Pattern: advance right crutch & left
foot together, then advance the left
crutch & right foot together.
Three-point gait:
-each crutch and only one leg
support weight. (Each is considered a
“point.”) The other leg is non-weight-
bearing. Used when patient has one leg
can fully bear weight and one leg can’t
bear weight. Most rapid gait speed,
provides the least amount of stability for the
patient. High energy required by patient.
 Pattern: advance crutches & injured
leg first, followed by unaffected leg in
a step through or step to pattern.
Four-point gait
each crutch and each leg move
separately. (Each of the four “points”
supports weight.) this gait pattern is used
when there's lack of coordination, poor
balance and muscle weakness in both LE,
as it provides slow and stable gait pattern
with three points support. Provides
maximum stability for patient and low
energy required by patient.
 Pattern: advance right crutch, then
left foot, left crutch, right foot.
None Weight Bearing
o Swing-to gait: A person with a non-
weight bearing injury generally
performs a "swing-to" gait: lifting the
affected leg, the user places both
crutches in front of himself, and then
swings his uninjured leg to meet the
crutches.
o Swing-through or tripod gait, the
client stands on the strong leg, moves
both crutches forward the same
distance, rests his or her weight on the
palms, and swings forward slightly
ahead of the crutches. Because this
gait is fast, the client should learn to
balance before attempting it. The
client who is allowed to put weight on
only one leg must hold up the other
leg, bending the knee (not bending
at the hip).
SWING -TO / SWING – THROUGH GAIT
Steps in Sitting down and Getting up of the
chair
o Stand to Sit/ Sitting down:
1. Stand in front of the chair with the
seat of the chair touching the back of
your legs.
2. Place both crutches in the hand on
the side of your injured leg.
3. Place the other hand on the arm rest
or side of the chair.
4. Sit down and slide back.
o Sit to Stand/ Getting up:
1. Hold both crutches in the hand on
the side of your good leg.
2. Slide to the front edge of seat.
3. Both feet flat on the floor (injured leg
NWB).
4. Place your other hand on the armrest
or side of the chair or side of the chair.
5. Push yourself up, placing weight on
the good leg and the crutches.
6. Transfer one crutch to the side of
affected leg. Stand in tripod position,
before walking.
HOW TO SIT DOWN and GET UP WITH A
CRUTCH
CLIMBING UP THE STAIRS
 The patient places the unaffected
leg on the first stair tread.
 The patient transfers his or her weight
to the crutches.
 The patient moves the crutches and
affected leg up to the stair tread and
continues to the top of the stairs.
 Have the patient stand in the tripod
position facing the stairs.
 The patient then transfers his or her
weight to the unaffected leg, moving
up onto the stair tread.
GOING DOWN THE STAIRS
 The patient transfers his or her weight
to the crutches.
 Have the patient stand in the tripod
position facing the stairs.
  The patient moves the unaffected
leg down to the stair tread and
continues down the stairs.
 The patient moves the crutches and
affected leg down to the stairs tread.
 The patient transfers weight to
unaffected leg.
Ambulation with a
Walker
PURPOSE: To ensure safe ambulation with
the walker and to increase endurance,
postural stability, control during transitional
movements, and dynamic balance.
CONSIDERATIONS: Walker is used for
patients who use as assistive device for
walking due to muscle weakness or
balance problems.
EQUIPMENT: Gait Belt Walker with secure
rubber suction cups on all legs, no rough or
damaged edges on hand rests
It is important to start walking soon after
injury or surgery but you will need support
while your leg is healing. A walker can give
you support as you start to walk again.
There are many types of walkers;
 Some walkers have no wheels, 2
wheels or 4 wheels. Some can also
get a walker with brakes, a carrying
basket and a sitting bench. Any
walker you use should be easy to fold
so that you can transport it easily.
 Your surgeon/physical therapist will
help you choose the type of walker
that is best for you.
WALKER BASICS
If your walker has wheels, you will push it
forward to move forward. If your walker
does not have wheels, then you will need to
lift it and place it in front of you to move
forward.
All 4 tips on your walker need to be on
the ground before you put your weight on
it.
a. Look forward when you are walking
not down at your feet.
b. Use a chair with an armrest to make
sitting and standing easier.
c. Make sure your walker has been
adjusted to your height. The handles
should be at the level of your hips.
Your elbow should be slightly bent
when you hold the handles.
d. Ask your health care provider for
help, if you are having problems using
your walker.
HOW TO WALK WITH YOUR WALKER
 Push or lift your walker a few
inches/centimeters or arm’s length in
front of you.
 Make sure all 4 tips or wheels of your
walker are touching the ground
before taking a step.
 Step forward with your weak leg first.
If you had surgery on both legs, start
with the leg that feels weaker.
 Then step forward with your other leg,
placing it in front of the weaker leg.
Repeat steps 1-4 to move forward. Go
slowly and walk with good posture, keeping
your back straight.
SITTING TO STANDING
Follow the steps when you get up from a
sitting position.
 Place the walker in front of you with
the open side facing you.
 Make sure all the 4 tips or wheels of
your walker are touching the ground.
 Lean slightly forward and use the
arms to help you stand up. Do not
push on or tilt the walker to help you
stand up. Use the chair /armrest or
handrail if they are available. Ask for
help if you need it.
 Grab the handles of the walker.
 You may need to take a step forward
to stand to straight.
 Before starting to walk, stand until you
feel steady and are ready to move
forward.
STANDING TO SITTING
 Back up to your chair, bed or toilet
until the seat touches the back of
your legs.
 Make sure all 4 tips or wheels of your
walker are touching the ground.
 Reach back with the hand and grab
the armrest/bed or toilet behind you.
If you had surgery on both legs, reach
back with one hand then the other
hand.
  Lean forward and move your weaker
leg forward (the leg you had surgery
on)
 Slowly sit down and then slight back
into position.
STEPING UP OR DOWN A STEP
When you go up and down stairs:
 Place the walker on the step in front
of you if you are going up. Place it
beneath the step if you are going
down. Make sure all 4 tips or wheels
are touching the ground
 To go up, step up with your strong leg
first. Place all your weight on the
walker and bring your weakened leg
up to the step.
 To go down, Step down with your
weaker leg first. Place all your weight
on the walker. Bring your strong leg
down next to your weaker leg.
SAFETY TIPS
 When walking start with your weaker
leg. If you had surgery, this is the leg
you had surgery on.
 When going up a step, start with your
stronger leg. When going
 Down a step start with the weaker
leg: “Up with the good down with the
bad”
 Keep space between you and your
walker and keep your toes inside your
walker. Stepping too close to the
front or tips/wheels may make you
lose your balance.
 Make changes around your house to
prevent falls.
 Make sure any loose rugs, rug corners
that stick up are secured to the
ground so you do not strip or tangled
in them.
 Keep your floors clean and dry.
 Wear shoes or slippers with rubber or
other non-stick soles. Do not wear
shoes with heals or leather soles.
 Check the tips and wheels of your
walker and replace them if they are
worn.
 Attach a small bag/basket to your
walker to hold small items so that you
can keep both hands on your walker.
 Do not try to use stairs/escalators
unless a physical therapist has trained
you how to use them.
PROCEDURE
1. Adhere to Standard Precautions.
2. Explain procedure to patient.
3. Assist the patient to put on socks and
nonskid shoes.
4. Apply gait belt.
COMING TO STAND
1. Position the walker in front of the
patient.
2. Assist the patient to a standing
position by straightening your legs as
you lift with the gait belt and the
patient pushes down with his hands
on the mattress.
3. Patient leans forward and pushes up
with arms from the chair arm rest or
bed to come to stand.
4. The person assisting should use an
underhand grasp on the belt and
assist the patient to a standing
position.
5. Instruct the patient to position his/her
body within the frame of the walker
and ask the patient to grasp the hand
rests securely. a. Check height of
walker to ensure hand rests are at the
level of the top of the femur and that
elbows are flexed at a 250-300-
degree angle.
WALKING INSTRUCTIONS
1. Instruct the patient to move the
walker forward by lifting it up,
moving it forward and setting it
down. Instruct the patient to
position the walker so the back
legs of the walker are even with
the patient's toes. The patient
should avoid sliding the walker.
2. Instruct the patient to take a step
forward with the weak leg.
3. 3.Instruct the patient to move
his/her strong leg forward.
4. Instruct the patient to take short
steps and keep his/her head up
and eyes looking forward.
5. Walk the patient the distance
instructed by supervisor/nurse as
indicated in the plan of care.
6. Repeat steps while walking to the
side and slightly behind the
patient, alert at all times.
RETURNING TO SIT
 As the patient approaches the chair
(or bed), the patient turns in small
circles toward the stronger side.
  Assist the patient back up to the chair
after ambulating until the chair can
be felt against the patient’s legs.
 The patient reaches for one arm rest
at a time.
 The patient lowers to the chair in a
controlled manner.

AFTER CARE:
1. Remove gait belt and replace
equipment.
2. Make sure the patient is comfortable.
3. Use alcohol-based hand rub for hand
hygiene.