OXYGEN THERAPY Administering Oxygen via Nasal Cannula

Question: Making a Difference Everyday

What is Oxygen? Definition: • A nasal cannula is a simple,
Answer : Oxygen , is a clear , odorless gas comfortable device for delivering oxygen to a
client. The two tips of the cannula, about 1.5 cm
that constitutes approximately 21% of the air
(1/2 inch) long, protrude from the center of a
we breath and is necessary for proper
functioning of all living cells. disposable tube and are inserted into the
nostrils.
Question:
• Oxygen can be delivered to the patient
Why do we need Oxygen?
through a variety of devices. Each has a specific
Answer : Oxygen is needed by the cells to function and oxygen concentration. The device
maintain the different cellular activities in our selected is based on the patient’s condition and
body. oxygen needs. A nasal cannula is used to deliver
Question: What condition needs for an from 25 ml per minute to 6 L per minute of
Oxygen therapy? oxygen.
Answer:O2 therapy is prescribed for people Purpose:
who can’t get enough oxygen on their own.
• To treat hypoxia because it serves as effective
EX.. COPD mechanism for oxygen delivery.
Pulmonary fibrosis • To deliver relatively low concentration of
Pneumonia oxygen when only minimal oxygen support is
required.
severe asthma attack
• To allow uninterrupted delivery of oxygen
cystic fibrosis
while the client ingests food or fluids.
Question: What are the symptoms of low
oxygen supply? • Flow meter connected to oxygen supply

Answer: • Humidifier with sterile distilled water

headache • Nasal cannula and

shortness of breath • Oxygen tubing
fast heartbeat • Oxygen source
coughing/ sneezing
• Gauze
wheezing
• “No smoking” sign
confusion

bluish discoloration of the skin,

EQUIPMENT
fingernails, lip Oxygen nasal cannula

Making a Difference Everyday

• The release of 02 will vary depending on the
flow.
– 24-38% Flow: 1-2 liters
– 30-35% Flow: 3-4 liters
– 38-44% Flow: 5-6 liters
ASSESSMENT
1. Observe for patent airway and remove
airway secretions. Observe for signs and
symptoms associated with hypoxia
R: Assessment provides the nurse with baseline
data. Secretions can plug the airway, decreasing
the amount of oxygen that is available for gas
exchange in the lungs.
2. Review patient medical record for order for
oxygen. Note method of delivery, flow rate and
duration of oxygen therapy
R: Ensure safe And accurate O2 administration
• Assess the skin and mucous membrane color :
presence of cyanosis, mucus , sputum
production and impedance of flow
• Breathing pattern: note depth of respiration
and presence of tachypnea, bradypnea, or
orthopnea
• Chest movements: Note whether there are
any intercostal, substernal, suprasternal,
supraclavicular or tracheal retractions during
inspiration or expiration.
• Chest Configuration: e.g. kyphosis
• Lung sounds audible by auscultating the chest
• Presence of any signs of oxygen toxicity:
tracheal irritation and cough, dyspnea, and
decreased pulmonary ventilation.
PLANNING
1. Obtain necessary equipment and place at
patient’s bedside.
R : Having necessary supplies readily at hand
enhances organization and efficiency in
applying nasal cannula.
2. Explain to patient the purpose of oxygen
mask and show how mask fits.
R : It alleviates anxiety and promotes
cooperation.
3. Place “oxygen in use” and “no smoking” signs
at entrance to client’s room and over head of
bed.
R: This is to prevent fire since oxygen helps in
combustion.
IMPLEMENTATION
1.Wash hands and attach nasal cannula to
oxygen tubing
R : Hand washing deters the spread of
microorganisms.
2. Attach nasal cannula and oxygen tubing to
humidified oxygen source.
R: Directs flow of oxygen into client’s upper
respiratory tract
• 3. Adjust oxygen flow rate to prescribed
dosage, usually between 1-6L/min , observe
that water humidifier is bubbling
R: Ensures correct oxygen delivery
• Connect nasal cannula to oxygen setup with
humidification, if one is in use. Adjust flow rate
as ordered by physician. Check the oxygen is
flowing out of prongs.
R: Oxygen forced through a water reservoir is
humidified before it is delivered to the patient,
thus preventing dehydration of the mucus
membranes.
4. Place tips of cannula into patient’s nares
R: Ensures patency of delivery device and
accuracy of oxygen flow rate
• 5. Adjust elastic headband or plastic slide until
cannula fits snugly and comfortably.
R: Client is more likely to keep apparatus in
place if it fits comfortably
• Place the prongs in patient’s nostrils. Adjust
according to type of equipment:
a. Over and behind each ear with adjuster
comfortably under chin or
b. Around patient’s head.
R: Correct placement of the prongs and fastener
facilitates oxygen administration and patient
comfort.
6. Allow sufficient slack on oxygen tubing and
secure to patient’s clothes
R: To prevent dislodgement of the tube
7. Check cannula every eight hours
R: To check the patency of the cannula
8. Keep humidification jar filled at all times
• 9. Assess patient’s nares and external nose for
skin breakdown every 6-8 hours.
R: Oxygen therapy can cause drying of nasal
mucosa. The delivery device can cause skin
breakdown were the device meets the face,
neck, and ears.
• Use gauze pads at ear beneath tubing as
necessary.
R: Pads reduce irritation and pressure and
protect the skin.
• Encourage patient to breathe through nose
with mouth closed.
R: Nose breathing provides for optimal delivery
of oxygen to patient.
10. Remind the physician to obtain ABG’s 20
minutes after initiation of therapy or change in
oxygen
concentration.
R: Assessment of oxygen saturation helps the
nurse evaluate effectiveness of therapy.
11. Check physician’s orders and flow of oxygen
through cannula at least every 8 hours. Wash
hands.
R: It permits early detection of inadequate flow
rate
• Perform hand hygiene.
• Assess and chart patient’s response to
therapy.
R: Patient’s respirations, color, breathing
pattern, and chest movements indicate
effectiveness of oxygen therapy.
• Remove and clean cannula and assess nares at
least every 8 hours or according to agency
recommendations. Check nares for evidence of
irritation or bleeding.
R: The continued presence of cannula causes
irritation and dryness of mucus membranes.
• Document the amount of oxygen applied, the
patient’s respiratory rate, oxygen saturation,
and lung sounds.
R: Documentation ensures continuity of care
and ongoing assessment record.
Evaluation
1. Reassess patient to determine response to
administration of oxygen by nasal cannula
R: Evaluate effectiveness of interventions
2. Record and reporting
a. record nurses’ notes at beginning and end of
nursing shift and include the change of shift
report of the following :
oxygen therapy, respiratory assessment
findings, method of oxygen delivery, flow rate,
patient’s response and adverse reactions or side R : Having necessary supplies readily at hand
effects. enhances organization and efficiency Making a
Difference Everyday
R: Recording promotes continuity of care and
enhance communication 2. Explain to patient the purpose of oxygen
nasal catheter mask and show how the catheter
UNEXPECTED SITUATION fits.
• Patient was fine on oxygen delivered by nasal R : It alleviates anxiety and promotes
cannula but now is cyanotic, and the pulse cooperation.
oximeter reading is <93%.
3. Place “oxygen in use” and “no smoking” signs
• Areas over ear or back of head are reddened at entrance to client’s room and over head of
bed.
Inserting a Nasal Catheter
R: This is to prevent fire since oxygen helps in
ASSESSMENT
combustion.
• Observe for patent airway and remove airway
IMPLEMENTATION
secretions. Observe for signs and symptoms
associated with hypoxia 1. Wash hands and attach nasal catheter to
oxygen tubing. Attach tubing to oxygen source.
• Review patient medical record for order for
Water in humidifier should be bubbling.
oxygen. Note method of delivery, flow rate and
duration of oxygen therapy. R: Hand washing deters the spread of
microorganisms.
PLANNING
2. Set flow rate to 2-3 L/min before inserting
1. Obtain necessary equipment and place at
catheter. Prepare the micropore tape.
patient’s bedside.
3. Prepare the lubricant at the wrapper. Wear
• Correct size of nasal catheter, micropore tape
gloves.
• Oxygen tubing
R: Gloves help in preventing infection.
• Water soluble lubricant
4. Measure proper length of catheter to be
• Humidifier inserted: measure distance from patient’s nose
to earlobe and mark
• Sterile distilled water
correct point with piece of tape.
• Oxygen source
5. Lubricate tip of catheter with watersoluble
• Oxygen flow meter
lubricant.
• Tongue depressor
R: It helps prevent drying of mucous membrane.
• Flashlight
6. Gently place catheter into the nostril. Glide
• “No smoking” sign catheter medially along floor of nasal cavity.
Stop at pre-marked point. Secure catheter
temporarily at the cheek
R: Correct placement of prongs facilitates
oxygen administration and comfort of client.
7.Inspect oral cavity using tongue depressor and
flashlight. Tip of the catheter should be visible
on either side of uvula.
8. Withdraw catheter tip 0.6 cm (0.25 in.) so
that it is no longer visible.
9. Secure catheter to patient’s nose.
10. Adjust flow rate to prescribed setting usually
1-6 min
R : Oxygen must be administered as prescribed.
11. Secure connecting tubing to patient’s gown
or bedding, allow slack in tube.
R : The cannula permits some freedom of
movement and does not interfere with the
client’s ability to eat or talk.
12. Remind the physician to obtain ABG’s 20
minutes after initiation of therapy or change in
oxygen concentration.
R : Assessment of oxygen saturation helps the
nurse evaluate effectiveness of therapy. Making
a Difference Everyday
13. Review physician’s order at least every 4
hours
R: It permits early detection of inadequate flow
rate.
14. Change catheter at least once daily or every
8 hours at most. Reinsert into opposite nares
and wash hands.
R: It prevents irritation and infection.
EVALUATION
• Reassess to determine patient’s response to
administration of oxygen by nasal cannula.
Observe for decreased anxiety, improved level
of consciousness and cognitive abilities,
decreased fatigue, absence of dizziness,
decreased pulse, regular rhythm, decreased
respiratory rate, return to normal blood
pressure, improved color.
• Record in nurses’ notes at beginning and end
of nursing shift and include the change or shift
report of the following:
oxygen therapy, respiratory assessment
findings, method of oxygen delivery, flow rate,
patient’s response and adverse reactions or side
effect.
R: It serves as legal record and allows
communication with health care team
members.
Administering Oxygen
via Mask
Oxygen Mask
Definition:
• An oxygen mask is shaped to fit snugly over
the client’s mouth and nose and is secured in
place with a strap. Most masks are made of
clear, pliable plastic or rubber that can be
molded to fit the face
Purpose:
• To provide moderate oxygen support and a
higher concentration of oxygen and humidity
that is provided by cannula.
• When a patient requires a higher
concentration of oxygen than a nasal cannula
can deliver, an oxygen mask used.
Types of Oxygen
Masks
Simple Face Mask
• Increasing the flow to 10 L/min may increase
oxygen concentration to about 50 %. If the flow
rate is less than 6 L/min (as cylinder nears
empty), the patient may re-breathe much of his
own exhalation and thus, the concentration of
oxygen delivered will be low, possibly severely
hypoxic.
Simple Face Mask
Venturi Mask
• This device utilizes a mechanical venturi effect
to increase oxygen flow rate into the mask; this
limits the dilution of the oxygen by air entering
into the mask.
• There are different types of venturimasks
available. Typically, these units deliver 24 - 28 %
oxygen at 4 L/min and 35 - 40 % oxygen at 8
L/min. This mask should only be used in a
clinical setting and should not be used in the
field.
Partial Rebreather or Medium
Concentration Mask
• This mask adds a reservoir bag to the simple
facemask. This mask appears similar to a non
re-breather mask. However, it is missing a
oneway valve between the reservoir bag and
the mask. The reservoir bag fills with oxygen.
Partial Re-breather Mask
Non-Rebreather Mask
• This mask consists of a mask that has a
reservoir bag attached. The bag is separated
from the mask by a one-way valve that prevents
air and patient exhalation from diluting the
oxygen in the reservoir bag. When the patient
inhales, the valve opens and the patient
breathes primarily oxygen.
• There are also one-way valves that cover the
holes on the mask to allow patient exhalation to
escape without allowing large quantities of air
to enter the mask.
• Some masks have this one-way valve on both
sides of the mask. These masks are prescription
only. If both sides are covered and gas flow
ceases, then the patient will not be able to
breathe because the valves keep air from
entering during inhalation. The common high
oxygen concentration mask has a one-way valve
on only one side so that if gas flow ceases, the
patient can still breathe. At a minimum oxygen
flow of 15 L/min, as long asthe reservoir bag is
kept filled and a good seal is maintained, this
mask can deliver 60 - 75% oxygen to the patient
EQUIPMENT
• Face mask or face tent
• Small-bore oxygen tubing
• Humidifier
• Sterile distilled water
• Oxygen source
• Oxygen Flow meter
• “No Smoking” sign
ASSESSMENT
• Observe for patent airway and remove airway
secretions. Observe for signs and symptoms
associated with hypoxia .
• Review patient medical record for order for
oxygen. Note method of delivery, flow rate and
duration of oxygen therapy.
PLANNING
1. Obtain necessary equipment and place at
patient’s bedside
R: Having necessary supplies readily at hand
enhances organization and efficiency in
applying oxygen mask
2. Explain to patient the purpose of oxygen • Venturi mask: percentage of FiO2 should
mask and show how mask fits. correlate with flow rate.

R: It alleviates anxiety and promotes • (Face tent mist should always be present)
cooperation.
R: It ensures patency of delivery device and
3. Place “oxygen in use” and “no smoking” signs accuracy of oxygen flow rate.
at entrance to client’s room and over head of
6. Observe for moisture in reservoir bag or large
bed.
bore oxygen tubing when face tent is used.
R: This is to prevent fire since oxygen helps in Remove the water from bag or tubing and
combustion. discard. Do not drain reservoir bag or tubing
into humidifying device.
IMPLEMENTATION
7. Humidity source should be checked every 4
1. Wash hands and attach facemask or tent to
hours. Container should be changed every 24
appropriately sized oxygen tubing.
hours.
R:Hand washing deters the spread of
R: Oxygen in high concentration can cause
microorganisms.
dryness of mucosa.
2. Attach facemask or tent and oxygen tubing to
8.Observe for pressure necrosis with tightly
humidified oxygen or gas source.
fitting mask every 2 hours.
R: Oxygen forced through a water reservoir is
R: Tight fitting mask and moisture from
humidified before it is delivered to the patient
condensation can irritate the skin on face.
to prevent dehydration of mucous membrane.
9. Remind the physician to obtain ABG’s 20
3. Adjust oxygen flow rate to prescribed dosage.
minutes after initiation of therapy or change in
R: Oxygen should be administered as oxygen
prescribed.
concentration.
4. Place facemask or tent on patient and adjust
R: Assessment of oxygen saturation helps the
to snug but comfortable fit.
nurse evaluate effectiveness of therapy.
R: When the mask fits the face properly, little
10. Check physician orders every 2-4 hours
oxygen escapes. Client is more likely to comply
with therapy if the equipment fits comfortably. R: It helps in early detection of inadequate flow
rate. It maintains legal record and allows
5. Observe for proper function of facemask or
communication with other health care team
tent:
members.
• Non re-breathing mask: reservoir bag will fill
11. Observe for gagging, retching, or vomiting
of exhalation and almost collapse on inhalation.
and remove mask if one of these occurs. Wash
• Partial re-breathing mask: reservoir bag your hands.
should fill on exhalation and almost collapse on
R: Masks may cause feeling of suffocation and
inhalation
patient needs frequent attention and
reassurance.
EVALUATION

1. Reassess patient to determine response to

administration of oxygen by nasal cannula

2. Record in nurses’ notes at beginning and end

of nursing shift and include the change or shift
report of the following: oxygen therapy,
respiratory assessment findings, method of
oxygen delivery, flow rate, patient’s response
and adverse reactions or side effect.

R: Documentation serves as legal record

Nasogastric Tube
Insertion
A nasogastric tube (NG TUBE) is a flexible tube
of rubber or plastic that is passed through the
nose, down through the esophagus, and into
the stomach. It can be used either to remove
substances from or add them to the stomach.
An NG tube is meant to be used only on a
temporary basis and is not for long term use.
• This type of tube allows the use of the
stomach as a natural reservoir of food.
• NG tubes may also be used to decompress or
irrigate the stomach, or to drain fluid or air from
the stomach.
Inserting a Nasogastric Tube
Purposes:
- To administer tube feedings and medications
to clients unable to eat by mouth or swallow a
sufficient diet without aspirating food or fluids
into the lungs.
- To establish a means of suctioning stomach
contents to prevent gastric distention, nausea,
and vomiting.
• To remove stomach contents for laboratory
analysis.
• To lavage(wash) the stomach in case of
poisoning or overdose of medications.
• This application would be used, for example,
to allow the intestinal tract to rest and promote
healing after bowel surgery.
• The NG tube can also be used to monitor
bleeding in the gastrointestinal tract or to help
an intestinal obstruction.
• The tube will be placed by a physician or a
nurse and typically in a hospital setting.
• It might be done while the patient is asleep
(sedated ), but is often done when the patient is
awake.
• The procedure is uncomfortable , but it
shouldn’t be painful ( that could indicate that
the tube is not placed properly)
• Potential problems:
- people with Ng tube might experience some
symptoms such as diarrhea, nausea, vomiting,
abdominal cramps or swelling.
RISK
- injury to the esophagus, throat, sinuses or
stomach. If an NG tube gets blocked or torn, or
if it comes out of place, there can be further
problems. Aspiration can also be a problem.
• Nasogastric tube of appropriate size (8 to 18
French)
ex. Levin tube-single lumen tube
Salem sump tube - with a double
lumen
• Stethoscope
• Small basin filled with ice or warm water
(optional)
• Water-soluble lubricant
• Normal saline solution (for irrigation only)
Equipment
• Tongue blade
• Asepto bulb syringe (20 to 50
mL)
• Flashlight
• Nonallergenic tape (1” wide)
• Tissues

• Glass of water with straw
• Topical analgesic (optional)
• Clamp
• Suction apparatus (if ordered)
• Bath towel or disposable pad
• Emesis basin
• Safety pin and rubber band
• Disposable gloves
• Tincture of benzoin
• pH paper
• Assess patency of patient's nares by asking
the patient to occlude one nostril and breathe
normally through the other.
• Select nostril through which air passes more
easily.
• Also, assess patient’s history for any recent
facial trauma or surgeries.
• Patients with facial fractures or facial
surgeries present a higher risk for misplacement
into the brain.
Assessment
•Many institutions require a physician to place
NG tubes in these patients.
•Auscultate bowel sounds and palpate the
abdomen for distention and tenderness.
•If abdomen is distended, consider measuring
the abdominal girth at the umbilicus to
establish a baseline.
The expected outcome to achieve when
inserting NG tube is that the tube is passed into
the patient’s stomach without any
complications.
Other outcomes may include the following:
• Patient demonstrate weight gain, indicating
improved nutrition
Outcome Identification and Planning
• Patient’s exhibit no signs and symptoms of
aspiration
• Patient rates pain as decreased from prior to
insertion
• Patient verbalizes an understanding of the
reason for
NG tube insertion.
Action : NGT Insertion
1. Check physician’s order for insertion of NG
tube.
• R: This clarifies procedure and type of
equipment required.
2. Explain the procedure to patient, discussing
with patient the need for the NG tube; answer
any questions that patient may have.
• R:Explanation facilitates patient cooperation
3. Gather equipment
4. Place a rubber NG tube in a basin with ice for
5-15 minutes or place a plastic tube in a basin of
warm water is needed.
• R: This provides for organized approach to
task.
• R: Cold stiffens the rubber tube, making it
easier to insert. Plastic tube may be place in
warm water to make it more flexible.
5. Perform hand hygiene. Don disposable
gloves.
• R: Hand hygiene deters the spread of
microorganisms
6. Assist the patient to high Fowler’s position, or
elevate the head of the bed 45 degrees, if
unable to maintain upright position, and drape
chest with bath towel or disposable pad.
Have emesis basin or tissue handy.
• R: Upright position is more natural for
swallowing and protects against aspiration, if
the patient should vomit. Passage of tube may
stimulate gagging and tearing of eyes.
7. Measure the distance to insert tube by
placing tip of tube at patient’s nostril and
extending to ear lobe and then to tip of xiphoid
process. Mark the tube with piece of tape.
• R: Measurement ensures that tube will be
long enough to enter patient’s stomach.
8. Lubricate tip of tube (at least 1’ to 2”) with
water soluble lubricant. Apply topical analgesic
to nostril and oropharynx, if ordered, or ask
patient to hold ice chips in mouth for several
minutes.
• R: Lubrication reduces friction and facilitates
passage of the tube into stomach. Water-
soluble lubricant will not cause pneumonia if
tube accidentally enters the lungs. Topical
analgesic or ice acts as a local anesthetic,
reducing discomfort. Topical analgesics must be
ordered by the physician.
Instillation of viscous
lidocaine 2%.
Nasogastric tube
lubrication with water-based lubricant.
Instillation of viscous lidocaine 2%.
9. Ask patient to lift head, and insert tube into
nostril while directing tube upward and
backward. Patient may gag when tube reaches
pharynx.
Provide tissues for tearing or watering of eyes
• R: Following normal contour of the nasal
passage while inserting the tube reduces
irritation and the likelihood of mucosal injury.
The gag reflex is readily stimulated by the tube.
Tears are a natural response as the tube passes
into the nasopharynx.
10. When pharynx is reached, instruct patient to
touch chin to chest. Encourage patient to sip
water through a straw or swallow even if no
fluids are permitted. Advance tube in
downward and backward direction when
patient swallows. Stop when patient breathes.
If gagging and coughing persist, check
placement of tube with tongue blade and
flashlight. Keep advancing tube until tape
marking is reached. Do not use force. Rotate
tube if it meets resistance.
R: Bringing the head forward helps close the
trachea and open the esophagus. Swallowing
helps advance the tube, causes the epiglottis to
cover the opening of the trachea, and helps to
eliminate gagging and coughing. Excessive
coughing and gagging may occur if the tube has
curled in the back of throat. Forcing the tube
may inquire mucous membranes.
11. Discontinue procedure and remove tube if
there are signs of distress, such as gasping,
coughing, cyanosis, and inability to speak or
hum.
• R: The tube is in the airway if the patient
shows sign of distress and cannot speak.
12. While keeping on one hand on tube,
determine that tube is in patient’s stomach:
12.1. Attach to syringe to end of tube and
aspirate a small amount of stomach contents.
• R: Keeping one hand on the tube stabilizes it
while position is being determined.
• R: The tube is in the stomach if its contents
can be aspirated: pH of aspirate can then be
tested to determine gastric placement.
12.2. Measure the pH of aspirated fluid using
pH paper or pH meter.
• R: The pH of gastric contents is acidic (4 or
less), compared with an average pH of 7.0 or
greater for respiratory fluid.
Because pH of intestinal fluid also is slightly
basic, this method will not effectively
differentiate between intestinal fluid and
pleural fluid.
12.3. Visualize aspirated contents, checking for
color and consistency.
12.4. Obtain radiograph of placement of tube (
as ordered by physician)
• R: Gastric fluid can be green with particles,
brown if old blood is present, clear or straw-
colored; tracheobronchial fluid is usually off-
white to tan; pleural fluid can be straw- colored
and is usually watery; intestinal fluid is usually
light to dark-golden yellow or brownish red-
green.
A small amount of blood tinge fluid may be seen
immediately after NG insertion.
13. Apply tincture of benzoin to tip of nose and
allow to dry. Secure tube with tape to patient’s
nose. Be careful not to pull tube too tightly
against nose.
13.1. Cut a 4” piece of tape and split bottom to
2” or use packaged nose tape for NG tubes.
13.2. Place unsplit end over bridge of patient’s
nose.
13.3. Wrap split ends under tubing and up over
onto nose.
R: Tincture of benzoin facilitates attachment of
tape. Constant pressure of the tube
against the skin and mucous membranes causes
tissue injury.
14. Attach tube to suction or clamp tube and
cap it according to physician’s orders.
• R: Suction provides for decompression of
stomach and drainage of gastric contents.
15. Secure tube to patient’s gown by using
rubber band or tape and safety pin. For
additional support, tube can be taped onto
patient’s cheek using a piece of tape. If double
lumen tube is used, secure vent above stomach
level. Attach at shoulder level.
R: This prevents tension and tugging on the
tube. Securing the double-lumen tube above
stomach level prevents seepage of gastric
contents and keeps the lumen clear for venting
air.
16. Assist with or provide oral hygiene at
regular intervals.
17. Remove disposable gloves and perform
hand hygiene. Remove all equipment and make
patient comfortable.
• R: Oral hygiene keeps mouth clean and moist
and promotes comfort.
• R: Hand hygiene deters the spread of
microorganisms.
18. Record insertion procedure and type and
size of tube, and measure tube form tip of nose
to end of tube. Also document a description of
gastric contents, including the pH, which nares
used, and patient’s response.
R: This facilitates documentation and provides
for comprehensive care. Measurement of tube
provides a baseline for future comparison.
Administering Tube Feeding
19.Explain procedure to patient. Use
stethoscope to assess bowel sounds.
R: This facilitates cooperation and provides
reassurance for patient. Presence of bowel
sounds may indicate functional GI tract.
20. Assemble equipment. Check amount,
concentration, type, and frequency of tube
feeding on patient’s chart. Check expiration
date of formula.
• R: This provides for organized approach to
task. Checking
ensures that correct feeding will be
administered. Outdated formula may be
contaminated.
21. Perform hand hygiene. Don disposable
gloves.
R: Hand hygiene deters the spread of
microorganisms. Gloves protect nurse from
exposure to blood or body substances.
22. Position patient with head of bed elevated
at least 30 degrees or as near normal position
for eating as possible.
• R: This position Minimizes possibility of
aspiration into trachea.
23. Unpin tube from patient’s gown. Check to
see that the NG tube is properly located in the
stomach.
• R: Even when initially positioned correctly, NG
tube left in place can become dislodged
between feedings. The instillation of water or
nourishment could lead to serious respiratory
problems if gastric tube is in the trachea or a
bronchus rather than in the stomach.
24. Aspirate all gastric contents with a syringe
and measure. Return immediately through
tube, saving small amount to measure gastric
pH. Flush tube with 30 mL of water for
irrigation. Proceed with feeding if amount of
residual does not exceed agency policy or
physician’s guideline. Disconnect syringe from
tubing.
R: This indicates gastric emptying time. A
residual of more than 100 ml from a
gastrostomy tube, 200 ml from an NG tube or
more than 10% to 20% above the hourly
feeding rate must be reported to the physician.
Fluid should be returned to stomach so as not
to cause any fluid or electrolyte looses. If
residual is a large amount as indicated by
above, confer with physician on whether to
discard aspirated contents or to replace them.
25. When using a large syringe (open system):
25.1. Remove plunger from 30 or 60 mL of
syringe.
25.2. Attach syringe to tube feeding, pour
premeasured amount of tube feeding to
syringe, open clamp, and allow food to enter
tube. Regulate rate, fast or slow, by height of
the syringe. Do not push formula with syringe
plunger.
R: Introducing the formula at a slow, regular
rate allows the stomach to accommodate to the
feeding and decreases GI distress. The higher
the syringe is held, the faster the formula
allows.
25.3. Add 30 to 60 ml of water for irrigation to
syringe when feeding is almost completed, and
allow it to run through the tube.
• R: Water rinses the feeding from the tube and
helps to keep it patent.
25.4. When syringe has emptied, hold syringe
high and disconnect from tube. Clamp tube and
cover end with sterile gauze with rubber and, or
apply cap.
R: By holding syringe high, the formula will not
backflow out of tube and onto patient.
Clamping the tube prevents air from entering
the stomach. Capping end of tube deters entry
of microorganisms. Covering the end protects
patient and linens from fluid leakage from tube.
26. Observe the patient’s response during and
after tube feeding.

• R: Pain may Indicate stomach distention,

which may lead to vomiting

27. Have patient remain in upright position for

at least 30 minutes to 1 hour after feeding.

• R: This position minimizes risk for backflow

and discourages aspiration, if any reflux or
vomiting should occur.

28. Wash and Clean equipment or replace

according to agency policy.

Remove gloves and perform hand hygiene.

• R: This prevents Contamination and deters

spread of microorganisms.

29. Record type and amount of feeding, residual

amount, verification of placement, and

patient’s response. Monitor blood glucose level,

if ordered by physician.

• R: This provides accurate documentation of

procedure. Many feedings contain high
amounts of carbohydrates.