Republic of the Philippines

CAVITE STATE UNIVERSITY

(CvSU)
DON SEVERINO DE LAS ALAS CAMPUS
Indang, Cavite
 
 
COLLEGE OF  NURSING
 
 
FUNDAMENTALS OF NURSING
  – NURS 04
RELATED LEARNING  EXPERIENCES
Name: _____________________________ Date: _______________
Year and Section: _________ Group No. __________

Competency Performance Checklist Inserting a NasogastricTube

3 - Able to perform
2 - Able t perform with assistance
1 - Unable to perform
PROCEDURE 4 3 2 1
1. Introduce yourself, and verify the client’s identity.
2. Perform hand hygiene, and observe other appropriate infection control
procedures.
3. Provide privacy.
4. Assess:
 The client’s history of nasal surgery or deviated septum.
 Patency of nares.
 Presence of gag reflex.
 Mental status or ability to cooperate with the procedure.
5. Explain the procedure to the client what you are going to do, why it is necessary,
nd how the client can cooperate. Secure consent for invasive procedure.
6. Determine the size of the tube to be inserted. Whether the tube is to be attached
suction or bedside bottle in the doctor’s order
7. Assemble the necessary equipment and supplies such as:
 Large or small-bore tube
 Non allergenic adhesive tape (2.5 cm wide)
 Disposable gloves
 Water soluble lubricant
 Facial tissues
 Glass of water and drinking straw
 20 to 50 mL syringe
 Basin
 Stethoscope
 Disposable pad or towel
 Clamp or plug (optional)
 Suction apparatus
 Gauze square or plastic specimen bag and elastic band
8. Assist the client to a Fowler’s position (30 to 45 degree) if his health condition
ermits and support his head on a pillow. Place a towel or disposable pad across
ient’s chest.
9. Assess the client’s nares
 Ask the client to hyperextend his head, and using a penlight, observe the
intactness of the tissues of the nostril, including any irritations or abrasions.
 Inspect the nares for any obstructions or deformities by asking the client to
breathe through one nostril while occluding the other.
 Select the nostril that has greater airflow.
10. Prepare the tube, plaster for anchoring, stethoscope, asepto syringe and bottle
s needed.
11. Put on the gloves
12. Determine how far to insert the tube
 Use the tube to mark off the distance from the tip of the client’s nose to the tip
of the earlobe and then from the tip of the earlobe to the tip of the xyphoid.
13. Insert the tube
  Lubricate the tip of the tube well with water soluble lubricant (1-3 in on the tip
of tubing)
 Initiate insertion (at least 3-5 in) and secure patient’s cooperation and facilitate
comfort by instructing patient to breath.
 Once the tube reaches the oropharynx, the client may gag and retch.
 Ask the client to tilt his head forward, and encourage the client to drink and
swallow.
14. Verify correct placement of the tube by:
 Aspirate stomach contents, and check for the pH as ordered.
 Auscultate air insufflation by placing a stethoscope over the client’s
epigastrum and injecting air into the tube while listening for a whooshing
sound using an asepto syringe.
 X-ray (most reliable)
15. Secure the tube by taping it to the bridge of the client’s nose. Anchor as
ossible.Secure end of the tubing and attach to the patient’s gown with a safety pin.
16. Remove gloves.
17. Document relevant information including:
 Date and time of the procedure
 How tolerated by the client
 Type and size of the tube
 Nostril used in the procedure
 Patency
 Amount, color and consistency or returns Lab tests done on gastric
contents (if possible)
Perfect Score: 68 TOTAL SCORE

___________________________ Student’s ___________________________

Name and Signature Clinical Instructor’s Name and
Signature