PAMANTASAN NG LUNGSOD NG MAYNILA COLLEGE OF NURSING

Medical- Surgical Nursing 1 SKILLS LABORATORY CHECKLIST

Name: Date:
Year Level and Block: Clinical Instructor:

Rating scale:
3 Performed correctly, systematically according to standard with correct
rationale.

2 Performed correctly, with correct rationale but not systematic.

1 Performed correctly, but not systematic and with inadequate rationale.

0 Performed incorrectly.

Procedure: Inserting a Nasogastric/ Nasointestinal Tube

PERFORMANCE
Remarks
PREPARATION RATIONALE
3 2 1 0

Purpose
● Permits nutritional
support through GI
tract.
● Allows evacuation
of gastric contents.
● Relieves nause
Assessment: ● Assessment on
● Doctor’s order for the patient
type and use of determines the
tube appropriateness of
● Size of previous NGT insertion.
tube used, if any
history of GI
problems requiring
use of tube.
● History of nasal or
sinus problems
● GI status, including
nausea, vomiting or
diarrhea; bowel
sounds ; abdominal
distension or girth:
passage of flatus.
 ● history of nasal
surgery or deviated
septum.
● Patency of nares.
● Presence of gag
reflex.
● Mental status or
ability to cooperate
with the procedure.
·

Assemble equipment and ● To save time and

supplies: energy
● NG tube (14-18
French)or
nasoinstestinal
small bore feeding
tube (8-12 french)
● Non allergenic
adhesive tape, 2.5
cm (1 inch) wide
● Non sterile gloves
● Water soluble
lubricant
● Facial tissue or
towel
● Glass of water and
drinking straw or ice
chips
● 30-60 ml syringe
with an adapter or
asepto syringe
● Emesin Basin
● Ph test strip
● Stethoscope
● Disposable pad or
towel
● Pen

Procedure

1. Introduce yourself and ● The proper

verify the client's identity. patient receiving
Explain to the client what the right
you are going to do, why it procedure is
is necessary, and how the ensured via
client can cooperate. patient
identification.
 ● Procedure
explanation
encourages
patient
compliance and
lowers anxiety

2. Perform hand hygiene ● Lessens the

and provide for client spread of
privacy. germs

3. Lower siderails and ● Lowering the

place the client in semi or side rails makes
high fowler’s position. it easier to work
in a level area,
and
High-Fowler's
location ensures
that the tube
inserts smoothly.

4. Check for nasal ● Determines which

patency: nostril will likely be
· Ask the client to used for the
breathe through one naris surgery and
while the other is minimizes harm
occluded. Repeat with during the
other naris. procedure.
· Have with both a ● Give the tube
client blow nose with both insertion process
nares open. Clean mucus a clear path.
and secretions from nares
with moist tissues or
cotton tipped swabs

5. Prepare Tube ● Ensuring the

· Measures length of tube tip is in
tubing needed by using the proper
tube and measure location and
distance from tip of nose provides an
to earlobe and then from appropriate
earlobe to sternal notch. length to
Mark the location on the insert.
tubing with a small piece ● Ice water stiffens
of tape. the tube, making
· If necessary, place insertion easier.
tube in ice-water bathe
· If a feeding tube with
weighted tip is used (small
bore feeding tube),
measure for distance as
instructed with package
insert. Insert guide wire
and prepare the tube as
instructed on package
insert
(usually by flushing
with10-20ml of saline
irrigation solution).

6. Don gloves and use ● Putting on gloves

water soluble lubricant or is an aseptic
dip feeding tube in water procedure.
to lubricate tip. maintains the
sterility of the
utilized
equipment.
● Reduces the risk
of illness by
preventing hand
contamination

7. Ask client to tilt head ● Aids in the tube's

backward; insert tube into smooth entry
clearer naris. into the naris

8. As the tube advanced, ● Aids with the

have client hold head and tube's entry into
neck straight and open the pharynx.
mouth ● Gives visual of
the tube as it
advances

9. When tube is seen and ● Swallowing

client can feel tube in helps the tube
pharynx, instruct client to to pass into the
swallow (offer ice chips or pharynx.
sips of water, unless ● Prevents the
contraindicated) tube to be on
the wrong site

10. Continue to advance ● Withdrawing

tube further into stops the tube
esophagus as client from being
swallows (if client coughs damaged or
or tube curls in throat, kinked into the
withdraw tube pharynx and esophagus.
repeat attempts); between ● Deep breaths
attempts, encourage client aid in
to take deep breaths. reducing pain
and anxiety in
patient

11. when tape mark on ● Aspiration of

the tube reaches entrance fluid and
to naris, stop tube checking for pH
intersection and check is an indicative of
placement by: that tube is in the
· Having client open right site
mouth for tube
visualization.
· Aspirating with
syringe, nothing color of
secretion return, and
checking pH of drainage
(pH between 1 and 5 may
indicate gastric secretions;
pH of 7 or higher may
indicate intestinal
placement)
or for old tube feeding (if
reinsertion).

12. Secure tube by ● Prevents

attaching commercially displacement of
prepared tube holder by: the tube
· Splitting 2 inches of ● Maintains tube
long tape strip, leaving 1 placements with
inch of strip intact patient
· Applying 1 inch movement
base of tape on bridge of
nose
Wrapping first one and
then the other side of split
tape around tube

13. Tape loop of tube to ● Prevents

side of client’s face (if displacement of
feeding tube) or pin to the tube
client’s gown (if sump ● Maintains tube
tube). placement with
patient
movement

14. Obtain order for chest ● X-ray

x-ray; delay tube feeding determines if
or flushing with fluid until the tube is in
doctor reads x-ray. the proper
placement of
the stomach
● Avoids harm
to the patient

15. Store stylet from ● Allows reuse of

small-bore feeding tube in stylet while
a plastic bag at the maintain
bedside after correct cleanliness
placement is confirmed by
x-ray.

16. Begin suction or tube

feeding as ordered. ● Initiation of
Therapy

17. Restore or ● Promotes

discard all cleanliness and
equipment appropriately efficiency for
future use
● Reduces
transfer or
organisms

18. Reposition client for

comfort. ● Facilitates
comfort

19. Remove and discard ● Reduces

gloves and perform hand transfer or
hygiene. microorga
nism

20. Document all relevant ● Accurate

information. procedure
· Date and time of specifics and
tube insertion effective team
· Color and amount of communication
drainage return iare provided via
· Ph result documentation
· Size and type of tube and evaluation.
· Client tolerance of ● Reassessing
procedure the patient’s
· Confirmation of tube status
placement by x-ray. identifies
positive
· Suction applied response to
(amount) or tube feeding procedure.
started and rate. ● Provides
objective
measure of
effectiveness
● Gives the patient
and the provider
a legal document
to sign
throughout the
procedure.

__________________________________

Signature over Printed Name of Student

Evaluated By:

______________________________________
Signature over Printed Name Clinical Instructor
 PAMANTASAN NG LUNGSOD NG MAYNILA COLLEGE OF NURSING
Medical- Surgical Nursing 1 SKILLS LABORATORY CHECKLIST

Name: Date:
Year Level and Block: Clinical Instructor:

Rating scale:
3 Performed correctly, systematically according to standard with correct
rationale.

2 Performed correctly, with correct rationale but not systematic.

1 Performed correctly, but not systematic and with inadequate rationale.

0 Performed incorrectly.

Procedure: Removing a NG tube

PERFORMANCE REMARKS
PREPARATION RATIONALE
3 2 1 0

1. Assess: ● Verifies Gi
· For the presence of functioning.
bowel sounds.
· For the absence of
nausea or vomiting the
tube is clamped.

2. Assemble equipment ● Promotes

and supplies efficiency and
· Disposable pad or saves time
towel
· Tissues
· Clean gloves
· 50ml syringe
· Plastic trash bag
3. Confirm the doctor’s ● Promote
order for removal of efficiency.
NGT. ● Ensure client
safety, appropriate
practice, and
appropriate patient

4. Assist the client to aa ● Facilitates in

sitting position if not removal of the
contraindicated tube.
● Reduces client
discomfort during
procedure.
● Ensure client
safety

5. Place the disposable ● Prevents secretion

pad or towel across the during procedure
client’s chest. from
contaminating the
patient's garments
and bedding.

6. Provide tissues to the ● Prevents

client to wipe nose and secretions to
mouth after tube contaminate
removal. bedding and
clothing

Procedure

1. Introduce yourself and ● The proper patient

verify the client's identity. receiving the right
Explain to the client what procedure is
you are going to do, why ensured via
it is necessary, and how patient
the client can cooperate. identification.
● Explaining
procedure
facilitates patient
cooperation and
reduces anxiety

2. Perform hand hygiene ● Reduces transfer

. of microorganisms

3. Provide privacy ● Preserves client’s

integrity.
● Reduces Anxiety
4. Detach the tube. ● Promotes
· Disconnect the efficiency during
NGT from the suction procedure.
apparatus if present. ● Facilitates in
· Unpin the tube smooth removal of
from the client’s the tube
gown.
Remove the adhesive
tape securing the tube
on the nose.

5. Remove the NG ● Clean gloves

tube. promote
· Put on clean cleanliness.
gloves ● Breathing deeply
· Ask the client to eases discomfort.
take a deep breath and ● The tube is
to hold it. continuously
· Pinch the tube with removed
the gloved hand throughout the
· Smoothly withdraw treatment to
the tube. lessen the
Place the tube in the patient's
plastic bag discomfort and
anxiety.
● The tube will
remain intact if
placed in a plastic
bag.
● Notify provider if
there are
abnormal
characteristics in
the tube after
withdrawal

6. Ensure client ● Promotes hygiene

comfort. ● Removes the
· Provide mouth secretion left over
care, if desired. from the treatment
· Assist the client
as required to blow nose.

7. Dispose of the ● Prevents transfer

equipment appropriately. of microorganisms
· Place the pad , ● Promotes
bag with tube and gloves cleanliness
in the receptacle
designated by
the agency.
8. Document all ● Accurate
relevant information. procedure
· Record the specifics and
removal of the tube, the effective team
amount and appearance communication
of any drainage, if the are provided via
tube was connected to documentation
suction, and relevant and evaluation.
assessments of the ● Reassessing the
client. patient’s status
identifies positive
response to
procedure
● Provides
objective measure
of effectiveness
● Provides a legal
document
between patient
and provider
during the
procedure

__________________________________

Signature over Printed Name of Student

Evaluated By:

______________________________________
Signature over Printed Name Clinical Instructor
 PAMANTASAN NG LUNGSOD NG MAYNILA COLLEGE OF NURSING
Medical- Surgical Nursing 1 SKILLS LABORATORY CHECKLIST

Name: Date:
Year Level and Block: Clinical Instructor:

Rating scale:
3 Performed correctly, systematically according to standard with correct
rationale.

2 Performed correctly, with correct rationale but not systematic.

1 Performed correctly, but not systematic and with inadequate rationale.

0 Performed incorrectly.

Procedure: Managing Enteral Tube Feeding

PERFORMANCE
PREPARATION RATIONALE REMARKS

3 2 1 0

Purpose
· Provides nutrition
supplementation to
clients who cannot
ingest adequate
amounts of nutrients
orally
Equipment:
· Stethoscope
· Ph paper (optional)
· Irrigation set with a
60 ml piston-type
syringe
· Washcloth and
towel
· Disposable gavage
feeding set (bag and
tubing appropriate for
pump)
· Tube feeding
product(at room temp.)
ordered by doctor
· Administration
pump
· Nonsterile gloves
· Glass or cup
· pen

Procedure

1. Perform hand ● Hand hygiene

hygiene and organize prevents transfer
equipment. Confirm of
orders for formula microorganisms.
frequency, route, and ● Equipment
rate, of feedings: organization for
· Change disposable use improves
gavage feeding sets productivity and
every 24 hours as per saves time.
manufacturer’s ● Confirming order
guidelines or agency prevents mistakes
policy and promotes
· Select tubing that efficiency of the
is compatible with procedure
feeding bag and pump
(if used).
· Determine amount
of free water to be
infused and pour into
cup.

2. Explain procedure to ● Procedure

client; provide for explanation
privacy. encourages
patient
cooperation and
lowers tension.
● Providing privacy
reduces
discomfort and
anxiety

3. Adjust bed to ● Promotes an

comfortable working adequate level to
height. work with
● Promotes
efficiency
4. Place or assist client ● Encourages an
in an appropriate appropriate level
position. The head of the to work at
bed should be elevated ● Promotes
in high Fowler’s position efficiency.
during and for at least ● In the high
30 min after the feeding fowlers position,
you can improve
your digestion
and avoid any
breathing-related
issues.

5. Don gloves ● Prevents

contamination
during procedure.
● Practices sterile
technique

6. Assess abdomen, ● Verifies Gi

noting the presence of functioning.
bowel sounds. Assess ● Prevents skin
skin at site as enteral breakdown
tube enters body (naris
or abdomen). provide
site care as per
doctor’s orders or
agency policy, if
appropriate.

7. Verify tube placement ● Prevents infusion

of formula into
pharynx or
pulmonary tree

8. To administer a ● Prevents muscle

continuous tube feeding:
· Prepare formula:
Remove formula from
refrigerator 30 mins. ● Check for leaks
Before hanging (if
applicable)
· Rinse bag and
tubing with water.
· Close roller clamp
on gavage tubing and
pour a 4 hours volume of
formula in bag.
· Open roller clamp
and allow formula to flow
cramps from
infusion of cold
solution
in bag or tubing
Closing roller
allows for adding
formula; adding 4
hour vol of
formula prevents
leakage from
excessive volume
and spoilage of
to end. Clamp tubing formula hanging
and insert into pump too long w/o ref
mechanism if used.

9. Attach feeding bag ● Initiation of

tubing to enteral tubing Therapy
to enteral tube attached
to client.

10. Set pump to deliver ● ensures optimum

appropriate volume and volume infusion
check infusion every 1-2 per hour
hr.

11. Every 4 hour : ● Determine degree

·Stop infusion; slowly absorption offeed
aspirate gastric prevents distensio
contents, taking care abdomen, possibl
not to pull on tube; and electrolyte im
and note amount ● Determines
of residual feeding. presence of
·If residual is greater peristalsis
than specified amount
as per orders
(commonly 100ml)
discard aspirated
volume from stomach,
cease feedings and
notify doctors.
·If residual feeding is
within acceptable
level return to stomach.
· Monitor bowel
sounds in all
abdominal quadrants.
Perform mouth care.

12. Irrigate tube every ● Prevents harness

2-3 hour and before and and growth on
after medication microorganisms
administration with between feedings
30-60ml of water or as ● Prevents
per doctor’s order or blockage and
agency policy. facilitates tube
patency
● Ensures proper
hydration after
feeding
13. Once each shift, ● Prevents harness
while irrigating enteral and growth on
tube after completing a microorganisms
dose of formula , rinse between feedings
bag and gavage tubing ● Prevents
with water. blockage and
facilitates tube
patency

14. Restore or discard ● Promotes

all equipment efficiency upon
appropriately future use
● Prevents transfer
of
microorganisms
● Promotes
cleanliness

15. Remove and discard ● Prevents transfer

gloves and perform hand of
hygiene. microorganisms
● Promotes
cleaniliness

12. Irrigate tube every ● Prevents harness

2-3 hour and before and and growth on
after medication microorganisms
administration with between feedings
30-60ml of water or as ● Prevents
per doctor’s order or blockage and
agency policy. facilitates tube
patency
● Ensures proper
hydration after
feeding

13. Once each shift, ● Prevents harness

while irrigating enteral and growth on
tube after completing a microorganisms
dose of formula , rinse between feedings
bag and gavage tubing ● Prevents
with water. blockage and
facilitates tube
patency

14. Restore or discard ● Promotes

all equipment efficiency upon
appropriately future use
 ● Prevents transfer
of
microorganisms
● Promotes
cleanliness

15. Remove and discard ● Prevents transfer

gloves and perform hand of
hygiene. microorganisms
● Promotes
cleaniliness

Managing Intermittent
Feeding

1. Follow steps 1-7 ● Promote proper

above execution of
procedure
● Promotes
efficiency and
safety of client
and nurse

2. Check for residual. ● Facilitates

appropriate
amount of feeding
needed

3. Crimp tube and ● Ensures accurate

connect syringe to volume of formula
enteral tube and to be feed
aspirate small amount of
contents to fill tube and
lower portion of syringe.

4. Fill syringe with ● Assists flow of

formula and allow to flow feeding by
slowly into enteral tube. gravity;maintain
Infuse formula holding tube patency
syringe 6 inches above
tube insertion site (nose
and abdomen)
follow with water.

5. Do not allow syringe ● Prevents air from

to empty until formula entering stomach
and water have
completely
infused.
6. Clamp enteral tube, ● Decrease reflux
remove syringe, and of feeding and
remind client to stay in possible
semi-fowlers or high aspiration
fowler’s position for at
least 30 min
after the feeding.

7. Check enteral tube ● Prevents

placement and residual aspiration of
feeding before each formula
tube
feeding.

8. Restore or discard all ● Promotes

equipment appropriately. efficiency upon
future use
● Prevents transfer
of
microorganisms
● Promotes
cleanliness

9. Remove and discard ● Prevents transfer

gloves and perform hand of microorganism
hygiene ● Promotes
cleanliness

10. Evaluate and ● Accurate

documents all relevant procedure
information. specifics and
· Assessment of tube effective team
placement and method communication
of confirmation are provided via
· Assessment site of documentation
tube entry and evaluation.
· Amount of residual ● Reassessing the
feeding patient’s status
· Amount and type identifies positive
of product given response to
· Amount of water procedure
given with and between ● Provides
feedings objective
· Route and method measure of
of delivery effectiveness
· Client position ● Provides a legal
during and after document
administration of between patient
products. and provider
· Client tolerance of during the
procedure procedure
Teaching performed.

__________________________________

Signature over Printed Name of Student

Evaluated By:

______________________________________
Signature over Printed Name Clinical Instructor