Helen B.

Gonzales

BSN -3

MODULE IN NCM 112 (RLE) SEMIFINALS

ACTIVITY 1:

1. Demonstrate your skills in inserting nasogastric tube.

Description

Nasogastric (NG) intubation is a procedure in which a thin, plastic tube is inserted into

the nostril, toward the esophagus, and down into the stomach. Once an NG tube is properly
placed and secured, healthcare providers such as the nurses can deliver food and medicine
directly to the stomach or obtain substances from it. The technique is often used to deliver food
and medicine to a patient when they are unable to eat or swallow. NG tubes are usually short
and are used mostly for suctioning stomach contents and secretions.

Types of Tubes

Tubes that pass from the nostrils into the duodenum or jejunum are called nasoenteric
tubes. The length of these tubes can either be medium (used for feeding) or long (used for
decompression, aspiration).

There are various tubes used in GI intubation but the following two are the most common:
  Levin tube. Is a single-lumen multipurpose plastic tube that is commonly used in NG
intubation.
 Salem sump tube. A double-lumen tube with a “pigtail” used for intermittent or
continuous suction.
Benefits

For patients to gain adequate nutrition and medication especially for those who are
unable to eat and drink. Also, NG intubation is a less invasive alternative to surgery in the event
an intestinal obstruction can be removed easily without surgery.

Indications

By inserting an NG tube, you are gaining an entry or direct connection to the stomach and
its contents. Therapeutic indications for NG intubation include:

 Gastric decompression. The nasogastric tube is connected to suction to facilitate

decompression by removing stomach contents. Gastric decompression is indicated for
bowel obstruction and paralytic ileus and when surgery is performed on the stomach or
intestine.
 Aspiration of gastric fluid content. Either for lavage or obtaining a specimen for
analysis.  It will also allow for drainage or lavage in drug over dosage or poisoning.
 Feeding and administration of medication. Introducing a passage into the GI tract will
enable a feeding and administration of various medications. NG tubes can also be used
for enteral feeding initially.
 Prevention of vomiting and aspiration. In trauma settings, NG tubes can be used to aid
in the prevention of vomiting and aspiration, as well as for assessment of GI bleeding.

Contraindications

Nasogastric intubation is contraindicated in the following:

 Recent nasal surgery and severe midface trauma. These two are the absolute
contraindications for NG intubation due to the possibility of inserting the tube
intracranially. An orogastric tube may be inserted, in this case.
 Other contraindications include: coagulation abnormality, esophageal varices, recent
banding of esophageal varices, and alkaline ingestion.

Risks and Complications

As with most procedures, NG tube insertion is not all beneficial to the patient as certain

risks and complications are involved:
  Aspiration. The main complication of NG tube insertion include aspiration.
 Discomfort. A conscious patient may feel a little discomfort while the NG tube is passed
through the nostril and into the stomach which can induce gagging or vomiting. A
suction should always be present and ready to be used in this case.
 Trauma. The tube can injure the tissue inside the sinuses, throat, esophagus, or stomach
if not properly inserted.
 Wrong placement. Unwanted scenarios such as wrong placement of an NG tube into
the lungs will allow food and medicine pass through it that may be fatal to the patient.
 Other complications include: abdominal cramping or swelling from feedings that are
too large, diarrhea, regurgitation of the food or medicine, a tube obstruction or
blockage, a tube perforation or tear, and tubes coming out of place and causing
additional complications
 An NG tube is meant to be used only for a short period of time. Prolonged use can lead
to conditions such as sinusitis, infections, and ulcerations on the tissue of your sinuses,
throat, esophagus, or stomach.

Nursing Considerations

The following are the nursing considerations you should watch out for:

 Provide oral and skin care. Give mouth rinses and apply lubricant to the patient’s lips
and nostril. Using a water-soluble lubricant, lubricate the catheter until where it touches
the nostrils because the client’s nose may become irritated and dry.
 Verify NG tube placement. Always verify if the NG tube placed is in the stomach by
aspirating a small amount of stomach contents. An X-ray study is the best way to verify
placement.
 Wear gloves. Gloves must always be worn while starting an NG because potential
contact with the patient’s blood or body fluids increases especially with inexperienced
operator.
 Face and eye protection. On the other hand, face and eye protection may also be
considered if the risk for vomiting is high. Trauma protocol calls for all team members to
wear gloves, face and eye protection and gowns.

Inserting a Nasogastric Tube (NGT)

Supplies and Equipment

 Gloves
 Nasogastric tube
 Water-soluble substance (K-Y jelly)
 Protective towel covering for client
 Emesis basin
  Tape for marking placement and securing tube
 Glass of water (if allowed)
 Straw for glass of water
 Stethoscope
 60-mL catheter tip syringe
 Rubber band and safety pin
 Suction equipment or tube feeding equipment

Preparation

Unlike the person that will perform the procedure, patients do not really have to
prepare for an NG intubation or feeding. However, a patient may need to blow their nose and
take a few sips of water (if allowed) before the procedure. Once the tube is inserted into the
nostril, the patient may need to swallow or drink water to help ease the NG tube through the
esophagus.

Anesthesia

In some institutions, topical anesthesia for nasogastric (NG) intubation have been

considered. It is used for pain relief and improve the possibility of successful NG intubation.

Another method used prior to the procedure is the viscous lidocaine (the sniff and swallow
method). It was found to significantly reduce the pain and gagging sensation associated with
NG tube insertion.

Alternative techniques include the following:

 Nebulization of lidocaine 1% or 4% through a face mask

 An anesthetic spray of benzocaine or a tetracaine/benzocaine/butyl aminobenzoate
combination
Steps in Inserting a Nasogastric Tube

Listed below are the step-by-step procedure in inserting a nasogastric tube.

1 Review the physician’s order and know the type, size, and purpose of the NG tube. It is
widely acceptable to use a size 16 or 18 French for adults while sizes suitable for children vary
from a very small size 5 French for children to size 12 French for older children.

2 Check the client’s identification band. Just like in administering medications, it is very

important to be sure that the procedure is being carried out on the right client.
3 Gather equipment, set up tube-feeding equipment or suction equipment mentioned
above. This is to make sure that the equipment is functioning properly before using it on the
client.

4 Briefly explain the procedure to the client and assess his capability to participate. It is not
advisable to explain the procedure too far in advance because the client’s anxiety about the
procedure may interfere with its success. It is important that the client relax, swallow, and
cooperate during the procedure.

5 Observe proper hand washing and don non-sterile gloves. Clean, not sterile, technique is

necessary because the gastrointestinal (GI) tract is not sterile.

6 Position client upright or in full Fowler’s position if possible. Place a clean towel over the

client’s chest. Full Fowler’s position assists the client to swallow, for optimal neck-stomach
alignment and promotes peristalsis. A towel is used as a covering to protect bed linens and the
client’s gown.

7 Measure tubing from bridge of nose to earlobe, then to the point halfway between the end
of the sternum and the navel. Mark this spot with a small piece of temporary tape or note the
distance. Each client will have a slightly different terminal insertion point. Measurements must
be made for each individual’s anatomy.

8 Wipe the client’s face and nose with a wet towel. Wipe down the exterior of the nose with
an alcohol swab. The NG tube will stay more secure if taped on a clean, non oily nose. If the
nose has been cleaned with an alcohol swab, the tape will stay more secure and the tube will
not move in the throat—causing gagging or discomfort later.

9 Cover the client’s eyes with a cloth. This protects the client’s eyes from any alcohol fumes
from the alcohol swab.

10 Examine nostrils for deformity or obstruction by closing one nostril and then the other and
asking the client to breathe through the nose for each attempt. If the client has difficulty
breathing out of one nostril, try to insert the NG tube in that one. The client may breathe more
comfortably if the “good” nostril remains patent.The blocked nasal passage may not be totally
occluded and thus you may still be able to pass an NG tube. It may be necessary to use the
more patent nostril for insertion.

11 Lubricate 4 to 8 inches of the tub with a water-soluble lubricant. The NG intubation is very

uncomfortable for many patients, so a squirt of Xylocaine jelly in the nostril, and a spray of
Xylocaine to the back of the throat will help alleviate the discomfort.
12 Flex the client’s head forward, tilt the tip of the nose upward and pass the tube gently into
the nose to as far as the back of the throat. Guide the tube straight back. Flexing the head aids
in the anatomic insertion of the tube.The tube is less likely to pass into the trachea.

13 Once the tube reaches the nasopharynx, allow the client lower his head slightly. Ask the
assistant to hold the glass of water. Ready the emesis basin and tissues. The positioning helps
the passage of the NG to follow anatomic landmarks. Swallowing water, if allowed, helps the
passage of the NG tube.

14 Instruct the client to swallow as the tube advances. Advance the tube until the correct
marked position on the tube is reached. Encourage the client to breathe through his
mouth. Swallowing of small sips of water may enhance passage of tube into the stomach rather
than the trachea.

15 If changes occur in patient’s respiratory status, if tube coils in mouth, if the patient begins
to cough or turns cyanotic, withdraw the tube immediately. The tube may be in the trachea.

16 If obstruction is felt, pull out the tube and try the other nostril. The client’s nostril may
deflect the NG into an inappropriate position. Let the client rest a moment and retry on the
other side.

17 Advance the tube as far as the marked insertion point. Place a temporary piece of tape
across the nose and tube. In this way, you can check for placement before securing the tube.
The tube may move out of position if not secured before checking for placement.

18 Check the back of the client’s throat to make sure that the tube is not curled in the back of
the throat. On instance, the NG will curl up in the back of the throat instead of passing down to
the stomach. Visual inspection is needed in this situation. Withdraw the entire tube and start
again if such thing occurred.

19 Check tube placement with these methods. Check the tube for correct placement by at
least two and preferably three of the following methods:

A. Aspirate stomach contents. Stomach aspirate will appear cloudy, green, tan, off-white,
bloody, or brown. It is not always visually possible to distinguish between stomach and
respiratory aspirates. Special note: The small diameters of some NG tubes make aspiration
problematic. The tubes themselves collapse when suction is applied via the syringe. Thus,
contents cannot be aspirated.

B. Check pH of aspirate. Measuring the pH of stomach aspirate is considered more accurate

than visual inspection. Stomach aspirate generally has a pH range of 0 to 4, commonly less than
4. The aspirate of respiratory contents is generally more alkaline, with a pH of 7 or more.

C. Inject 30 mL of air into the stomach and listen with the stethoscope for the “whoosh” of air
into the stomach. The small diameter of some NG tubes may make it difficult to hear air
entering the stomach.

D. Confirm by x-ray placement. X-ray visualization is the only method that is considered

positive.

20 Secure the tube with tape or commercially prepared tube holder once stomach placement
has been confirmed. It is very important to ensure that the NG tube is in its correct place within
the stomach because, if by accident the NG is within the trachea, serious complications in
relation to the lungs would appear. Securing the tube in place will prevent peristaltic movement
from advancing the tube or from the tube unintentionally being pulled out.

Outlook

After the procedure is done, with NG tube intact and secured, the primary purpose of it is now
ready to be applied. Patients equipped with the NG tube must maintain good oral hygiene and
the need to clean their nose regularly. The healthcare team is also entitled to check for any
irregularities such as signs of irritation, infection, or ulceration while the NG tube is in place.

ACTIVITY 2:
1. Compute your own Body Mass Index. Show your computation.

weight (kg) 50
BMI = = =21.1 kg/m²
height ² 2.37

2. Compute your own Ideal body weight. Show your computation

102 lb

6” x 5 lb / inch = 30 lb

132 + 13 lb depending on frame size

ACTIVITY 3:

1. Demonstrate SMBG using glucometer.

Description

A glucometer is a small, portable device that lets you check your blood sugars (glucose
levels) at home. Your healthcare provider will show you how to use a glucometer. First, you'll
put a test strip in the device. Then you'll prick your finger to get a small drop of blood that you
can put on the strip so it can be analyzed by the glucometer. Also called glucose meters, these
devices can tell you in seconds if your blood sugar is too low, too high, or on target. No matter
what type of diabetes you have, a glucometer can give you valuable information. 

Who Should Use a Glucometer?

You may need to use a glucometer regularly if you have:

 Type 1 diabetes
 Type 2 diabetes
 Latent autoimmune diabetes in adults, or LADA (type 1 that develops in adulthood)
 Gestational diabetes (similar to type 2 diabetes but occurs only during pregnancy)

Frequent glucometer use can help you:

 Check your blood sugar levels and overall control

 See how your glucose levels respond to exercise or stress
 Recognize what else makes your levels spike or crash
 Monitor the effects of medications and other therapies
 See how well you're meeting treatment goals
Glucose control is important because of both short-term and long-term health consequences of
unmanaged diabetes.

 Guidelines for Blood Glucose Monitoring

When to Test

Talk to your doctor about when and how often you should test your blood sugars. Make
sure you know what to do if your results are low or high. Your testing frequency may depend on
your type of diabetes and your treatment plan. Your healthcare provider will tell you what
testing schedule is best for you. That schedule may or may not be similar to the general
guidelines.

Type 2 Diabetes Doctor Discussion Guide

Get our printable guide for your next doctor's appointment to help you ask the right questions.

Type 1 Diabetes

Insulin is a hormone produced by the pancreas. It helps your cells use the glucose in
your blood. In type 1 diabetes, the pancreas stops making insulin or makes very little. That
makes frequent testing important. It helps ensure you have enough insulin to keep your blood
sugar levels stable. If you have type 1 diabetes, you may need to test your glucose levels four to
10 times per day.

You may test:

 Before eating (meals and snacks)

 Before and after exercise
 Before bed
 Possibly during the night

Type 2 and Gestational Diabetes

In type 2 and gestational diabetes (GD), your body still produces insulin, but it doesn't
use it efficiently. This is called insulin resistance and it makes blood sugar levels rise. If you have
one of these conditions, you may only need to test two to four times per day. You may test
much more often, though, especially when your diagnosis is new and your levels aren't yet
stable.

You may check:

 First thing in the morning and before bed

 Before each meal and before bed
  Before and two hours after each meal and before bed

Target Glucose Ranges

General guidelines for target glucose levels may or may not apply to you. Your healthcare
provider can tell you the ideal range for you. Levels can vary depending on:

 Age
 Sex
 Activity level
 Type of diabetes
 How long you've had diabetes
 Other health conditions

The American Diabetes Association says the following target range applies to most non-
pregnant adults with diabetes.

Pre-meal blood sugar 80 to 130 mg/dL

Post-meal blood sugarLess than 180 mg/dL
 Normal Blood Sugar Levels After Eating

Supplies You Need

Before you use your glucometer, make sure you have all the necessary supplies:

 Alcohol prep pad or soap and water

 A lancing device with a fresh lancet (used to draw blood)
 A test strip
 A way to record results

Using a Glucometer: Step-by-Step

Glucometers only need a drop of blood. The meters are small enough to travel with or
fit in a purse. You can use one anywhere.

Each device comes with an instruction manual. And typically, a healthcare provider will
go over your new glucometer with you too. This may be an endocrinologist or a certified
diabetic educator (CDE), a professional who can also help develop an individualized care plan,
create meal plans, answer questions about managing your disease, and more.
These are general instructions and may not be accurate for all glucometer models. For example,
while the fingers are the most common sites to use, some glucometers allow you to use your
thigh, forearm, or the fleshy part of your hand. Check your manual before using the device.

Before You Start

Prepare what you need and wash up before drawing blood:

 Set out your supplies

 Wash your hands or clean them with an alcohol pad. This helps prevent infection and
removes food residue that might alter your results.
 Allow the skin to dry completely. Moisture can dilute a blood sample taken from the
finger. Don't blow on your skin to dry it, as that can introduce germs.

Getting and Testing a Sample

This process is quick, but doing it right will help you avoid having to re-stick yourself.

1. Turn on the glucometer. This is usually done by inserting a test strip. The glucometer
screen will tell you when it's time to put blood on the strip.
2. Use the lancing device to pierce the side of your finger, next to the fingernail (or another
recommended location). This hurts less than lancing the pads of your fingers.
3. Squeeze your finger until it has produced a sufficient-size drop.
4. Place the drop of blood on the strip.
5. Blot your finger with the alcohol prep pad to stop the bleeding.
6. Wait a few moments for the glucometer to generate a reading.

Recording Your Results

Keeping a log of your results makes it easier for you and your healthcare provider to build a
treatment plan.

You can do this on paper, but smartphone apps that sync with glucometers make this very easy.
Some devices even record readings on the monitors themselves.

Follow your doctor's orders for what to do base on the blood sugar reading. That may include
using insulin to bring your level down or eating carbohydrates to bring it up.

2. Demonstrate insulin therapy.

INSULIN THERAPY

Insulin

 A hormone secretion by the beta cells of the islets of Langerhans of the pancreas that is
necessary for the metabolism of carbohydrates, proteins and fats: a deficiency of insulin
result in diabetes mellitus.
  Insulin is a hormone made in your pancreas, a gland located behind your stomach.
Insulin allows your body to use glucose for energy. Glucose is a type of sugar found in
many carbohydrates.

The body processes glucose like this:

 After a meal or snack, carbohydrates are broken down in your digestive tract and
changed into glucose.

 That glucose is then absorbed into your bloodstream through the lining of your small
intestine.

 Once glucose is in your bloodstream, insulin signals cells throughout your body to
absorb the sugar and use it for energy.

Insulin also helps balance your blood glucose levels. When there’s too much glucose in your
bloodstream, insulin tells your body to store the leftover glucose in your liver. The stored
glucose isn’t released until your blood glucose levels decrease. Your blood glucose levels may
decrease between meals or when your body is stressed or needs an extra boost of energy.

Type 1 diabetes is an autoimmune disease, which is a type of disease that causes the body
to attack itself. If you’re living with type 1 diabetes, your body cannot make insulin properly.
This is because your immune system has harmed the insulin-producing cells in your pancreas.
Type 1 diabetes is more commonly diagnosed in young people, although it can develop in
adulthood.

In type 2 diabetes, your body has become resistant to the effects of insulin. This means your
body needs more insulin to get the same effects. As a result, your body overproduces insulin to
keep your blood glucose levels normal. After many years of this overproduction, the insulin-
producing cells in your pancreas burn out. Type 2 diabetes can affect people of any age.

Managing diabetes with insulin

Injections of insulin can help manage both types of diabetes. The injected insulin acts as
a replacement for or a supplement to, your body’s natural insulin. People living with type 1
diabetes can’t make insulin, so they must inject insulin to control their blood glucose levels.
Many people living with type 2 diabetes can manage their blood glucose levels with lifestyle
changes and oral medication. However, if these treatments don’t help control glucose levels,
people living with type 2 diabetes may also need supplemental insulin.

Types of insulin treatments

All types of insulin produce the same effect. They are used to mimic the natural
increases and decreases of insulin levels in the body during the day. The makeup of different
types of insulin affects how fast and how long they work.

The type of insulin you’ll be prescribed will vary depending on things like:

 your age

 your activity level

 how long it takes your body to absorb insulin

 how long insulin stays active in your system

When it
peaks in
Insulin type Onset Duration When taken
your
system

Taken with meals, usually with the

Ultra-rapid 2 to 15 first bite of a meal.
30-60 min 4 hours
acting min Commonly used along with long-
acting insulin.

Taken with meals, typically right

2 to 4
Rapid-acting 15 min 1 hour before a meal. Commonly used along
hours
with longer-acting insulin.

Taken with meals, typically right

Rapid-acting 10 to
30 min 3 hours before a meal. Commonly used with
inhaled 15 min
injectable long-acting insulin.

Regular or 2 to 3 3 to 6 Taken with meals, typically 30 to 60

30 min
short-acting hours hours minutes before a meal.
 Taken once or twice a day. Covers
Intermediate 2 to 4 4 to 12 12 to 18 your insulin needs for half a day or
acting hours hours hours overnight. Commonly used with
rapid- or short-acting insulin.

Taken once a day. Can be used with

2 doesn’t up to 24
Long-acting rapid- or short-acting insulin if
hours peak hours
needed.

Taken once a day. Can be used with

Ulta-long 6 doesn’t 36 hours
rapid- or short-acting insulin if
acting hours peak or more
needed.

Taken twice a day, commonly 10 to

30 minutes before breakfast and
5 to 60 varied 10 to 16
Premixed dinner. This type is a combination of
min peaks hours
intermediate- and short-acting
insulin.

Administration and dosage

Insulin is most commonly administered through a syringe, insulin pen, or insulin pump.

The type of insulin injection you use will be based on your personal preference, health needs,
and insurance coverage.

Your doctor or diabetes educator will show you how to give yourself the injections. You can
inject the insulin under the skin in many different parts of your body, such as your:

 thighs

 buttocks

 upper arms

 abdomen

How to choose the right method for injecting insulin

 Both syringes and insulin pens use a small needle to inject insulin into your body. There
are pros and cons to each, and which one you ultimately end up with will depend on your
lifestyle and your doctor’s advice.

Things to know about insulin syringes:

 They come in a few different sizes.

 Your doctor will tell you how much insulin you need per dose.

 You will usually draw the insulin into the syringe when you need it.

 They’re not as discreet as an insulin pen.

Things to know about insulin pens:

 Some pens use cartridges that are manually inserted into the pen.

 Other pens are prefilled and thrown away after all the insulin is used.

 Needles in pens are often smaller than those in syringes.

 Not all types of insulin can be used with a pen.

 Pens can be more expensive than syringes and are sometimes not covered by insurance.

How to take insulin without a syringe

There are two ways to get your insulin without using a syringe or needle. Your doctor will
decide if one of these options works for your personal needs.

Insulin pumps:

 deliver insulin continuously through a plastic tube placed semipermanently into the
fatty layer under your skin

 are typically placed in the stomach area or back of the upper arm

 can deliver insulin more accurately than a syringe

  need to be told to deliver additional insulin for meals

 may cause weight gain

 may cause infection

 may be expensive

Insulin inhalers:

 deliver ultra-rapid-acting insulin

 are typically used before a meal

 commonly must be used along with injectable, longer-acting insulin

 may cause less weight gain

 may cause coughing

 don’t give as exact doses compared with other methods

 require routine testing to monitor for side effects

Side effects and reactions

Side effects from injecting or receiving insulin are rare, but can occur in certain cases.
The symptoms of mild allergic reactions are swelling, itching, or redness around the injection
area. More severe insulin allergies may include nausea and vomiting. In either case, talk with
your doctor if you notice any of these signs. Hypoglycemia, or blood glucose levels that are too
low, can sometimes occur when you take insulin. It’s important to balance the insulin that you
give yourself with food or calories. If you exercise longer or harder than usual or don’t eat the
right amount of calories or carbs, your glucose level can drop too low and trigger low blood
sugar. Symptoms of low blood sugar include:

 fatigue

 inability to speak

 sweating
  confusion

 loss of consciousness

 seizures

 muscle twitching

 pale skin

Treatment

To treat hypoglycemia (less than 70mg/dL or the level your doctor has said is too low for
you), carry at least 15 grams of fast-acting carbohydrates with you at all times. That’s about
equal to any of the following:

 1/2 cup of non-diet soda

 1/2 cup of fruit juice

 5 Life Saver candies

 2 tablespoons of raisins

 3 to 4 glucose tablets