NCM 116 – SKILLS LAB LECTURE NOTES

GI INTUBATION
• Insertion of a flexible tube into the • PURPOSES:
stomach, or beyond the pylorus into o To provide feeding (gavage)
the duodenum or jejunum o To administer meds EXCEPT
• May be inserted through the mouth, ENTERIC
nose, or the abdominal wall o COATED MEDS
o To irrigate stomach (lavage)
o For decompression (drainage of
gastric content) → PRIOR TO
SURGERY
o To administer supplemental
fluids
TYPE OF TUBE
LOCATION PURPOSE DURATION OF USE
FEEDING
Nasogastric (NG) tube Inserted through the Enteral feedings; Short term tube feeding
nose, passing through sometimes, the tube is needs not exceeding six
the esophagus and into used to decompress the to eight weeks.*4
the stomach. stomach. weeks PEG TUBE
Nasojejunal (NJ) tube Inserted through the Used as an alternative In most cases, this is for
nose, passing by the to NG tube when the short term use (6-8
esophagus and the patient cannot tolerate weeks), but may be
stomach and straight feeding through the extended when the
into the small intestine. stomach, normally patient needs longer
done post gastric enteral feeding
surgery.
Gastrostomy tubes An opening is created Used for patients with Long term enteral
• PEG (percutaneous directly into the complicated health feeding
endoscopic stomach through a conditions where other
gastrostomy) small incision in the means of providing
• Rig (radiologically abdomen. nutrients into the body
Inserted is not feasible (i.e.,
gastrostomy) gangrene or cancer of
the stomach,
obstruction)
Jejunostomy tube (J Inserted through the Semi-permanent access Semi-permanent, 8
tube) stomach and into the for the patient who has weeks up.
small intestine had difficulty with
(jejunum). Another gastroparesis, nausea,
way may be done vomiting, or previous
through inserting the intolerance to gastric
tube directly through a feeding.
small Incision in the
abdomen where the
jejunum is.

TYPES OF GASTRIC TUBE

➴Levin Tube
— Single lumen
— Made up of plastic or rubber

DECELIS, G. P. 1
 NCM 116 – SKILLS LAB LECTURE NOTES

➴Salem Sump
— Radiopaque, clear plastic, double-lumen
gastric tube
— Blue port - inner, smaller lumen went
the larger suction-drainage to the
atmosphere by means of an opening at
the distal end of the tube; should be kept
above the patient’s waist to prevent
reflux

➴Sengstaken-Blakemore
— Rubber
— Two lumens are used to inflate the
gastric and esophageal balloons
— 3rd tube is reserved for suction or
drainage
— Compresses esophageal varices or
reduces GI hemorrhage

Nursing & Patient Care Consideration
• If patient is unconscious, advance the
tube between respirations to make sure
it does not enter the trachea → RESP
DISTRESS (Cyanosis)
o Stroke the neck of the
unconscious patient to
facilitate passage of the tube
down the esophagus ○ WOF
cyanosis while passing the
tube in an unconscious
patient. Cyanosis → tube has
entered the trachea
• If the patient has a nasal condition that
prevents insertion through the nose, the
tube is passed through the mouth
o Remove dentures, slide the
distal end of the tube over the
o Esophagotracheal fistula
o Gastric ulcerations
o Pulmonary & oral infections
• Extended-use NG tubes are made of
flexible, soft, plastic material with
manufacturer’s recommendations that
may include leaving the tube in place
for up to 30 days before changing the
tube.
tongue, and proceed the same
way as a nasal intubation ○
Make sure to coil the end tube
and direct it downward at the
pharynx
• Pain or vomiting after the tube is
inserted indicated tube obstruction or
incorrect placement.
• If the NG tube is not draining, the nurse
should reposition tube by advancing or
withdrawing it slightly (with
physician’s order). After repositioning,
always check for placement.
• Recognize the complications when the
tube is in for prolonged periods:
o Nasal erosion
o Sinusitis
o Esophagitis
• Assess the color, consistency, and odor
of gastric contents. Coffee ground-like
contents may indicate GI bleeding,
Report findings immediately.
• Tincture of Benzoin - use for
diaphoretic patient to adhere the tape
on skin

DECELIS, G. P. 2
 NCM 116 – SKILLS LAB LECTURE NOTES
NGT INSERTION
Infection control: STERILE
Position: HIGH FOWLER’S
NURSING RESPONSIBILITY/ INTERVENTIONS
1. Assess nasal patency
2. Measure tube (50 cm) →
ave 22-26 in → N-E-X
3. Lubricate tube: water
soluble (KY JELLY)
4. Nasopharynx: tilt head
back/hyperextend the
neck
5. Oropharynx: flex neck
6. Ask patient to swallow
7. Check the tube placement
Checking of tube placement:
1. X-ray - confirmatory
2. Aspirate gastric contents
(yellowish, greenish,
clear/colorless
3. Check gastric ph (1-4) →
5 or less
4. Insufflation - introduction
of air (5-20ml), auscultate WOF: abdominal cramps
epigastric area → (+)
gurgling sound →
borborygmi (common)
5. Place the tip of tube at
glass of water - (less
accurate) there should be
NO bubbles → x
aspiration
6. Measure the length of the
tube
NGT FEEDING
CLEAN TECHNIQUE
SEMI-FOWLER’S
1. Assess bowel sounds
2. Auscultate
3. Check residual volume:
100 ml hold the feeding;
check after 1 hr for 2 cons removal of gastric contents
hours; if still with high
GRV → refer
4. Flush with distilled water
(30-60 ml)
5. Feeding: Bolus - gravity
Infusion - by pump
6. Ht of feeding: 12 inches
7. Reflush: 30-60 ml 8.
8. Clamp - to prevent
introduction of air →
flatulence 9.
9. Remain at high-fowler’s
sitting, upright position 30
mins after the feeding
Mngt: STOP TEMPORARILY
Flatulence, crampy pain, reflex
vomiting
Mngt: SLOW THE FEEDING
NGT SUCTION/DRAIN
CLEAN TECHNIQUE
SEMI-FOWLER’S
1. Assess the patency 2.
2. Irrigate with NSS
WOF: Metabolic alkalosis →
(decreased HCL)
Salem-sump - low continuous
or high intermittent suction
Levin - low intermittent suction
NGT Removal:
1. Explain the procedure
2. Stop the feeding (tube
detached from the feeding
line)
3. Drain tube contents
4. Remove tape
5. Remove the tube in one
swift motions and dispose
of in the waste bag
6. Wipe the patient’s nose
7. Remove gloves, wash
hands and dispose waste
properly
8. Document

Percutaneous Endoscopic Gastrostomy Tube

Enteral Nutrition “Tube feeding”
• Nutrition delivered directly into the GI
tract, bypassing the oral cavity.
• Used when the functioning has a
functioning GI tract but is unable to
take any or enough oral nourishment
or when it is unsafe to do so
• Indications:
o Anorexia
o Orofacial fractures
o Head & neck cancer
o Neurologic/psychiatric
conditions that prevent oral
intake
o Extensive burns
o Critical illness
o Chemotherapy/radiotherapy
Feeding (PEG)
Tube Care:
1. Determine if left open or with dressing
2. 2 patient identifiers
3. Hand hygiene → clean gloves
4. Remove old dressing with drainage (fold
inside) → remove gloves inside out
5. Assess exit site: excoriation, drainage,
infection, or bleeding
6. Clean skin around the site with warm
water and mild soap or saline using 4x4
gauze
7. Apply thin layer of protective skin barrier
to exit site
8. Dressing as ordered: place a drain-gauze
dressing over external bar or disc
9. Secure dressing 1
10. After care
DECELIS, G. P. 3
 NCM 116 – SKILLS LAB LECTURE NOTES
11. Document 5. Check the residual volume/formula. If 100
Procedure: ml or more, verify if the feeding will be
1. Explain the procedure to the patient administered
2. Wash hands - clean technique
3. Provide privacy
4. Assemble the materials
5. Position : Semi-Fowler’s
6. Wear clean gloves
7. Place a towel over the abdomen
8. Check or placement
a. Bowel sounds
b. Unclamp
c. Aspirate gastric contents 6. Administer feeding slowly. Hold syringe
9. Pinch the proximal end of the feeding tube 7-15 cm (3-6 inches) above the ostomy
(prevents air from entering the stomach) opening
10. Flush with 30-60 ml 7. Flush the tube with 20 ml of water
11. Administer the feeding 8. After feeding, remain in sitting position or
12. Flush with 30-60 ml slightly elevated right lateral position for
13. Reclamp at least 30 mins.
s 9. Assess peristomal skin
Administering Gastronomy/Jejunostomy
Feeding
1. Assess and prepare the client
2. feeding tube into the ostomy opening 10-
15 cm, if one is not already in place
3. Lubricate: water soluble
4. Check the patency of a tube sutured in
place. (pour 15-30 ml of water into the
syringe and allow the water to flow into
the tube)

Problems Related to Tube Feeding

Problem Cause
Clogged feeding tube
Improper placement of tube
Vomiting or Aspiration
Delayed gastric emptying;
increased residual volume
Corrective Measure
▪ Attempt to flush with water
▪ Special products are
available for unclogging
feeding tubes; do not use
soda and juice
▪ Hold feeding and notify
physician
▪ Maintain patient in SF
position
▪ Replace tube in proper
position
▪ Check tube position before
beginning feeding and
every 8hrs if continuous
feeding
▪ If GRV is >250 ml after
2nd gastric residual check,
consider a promotility
agent
▪ If GRV is >500 ml, hold
enteral nutrition and
reassess patient tolerance

DECELIS, G. P. 4
 NCM 116 – SKILLS LAB LECTURE NOTES
Potential for aspiration
Excessive diarrhea, vomiting
Dehydration
▪ Increase intake and check
Poor fluid intake
▪ Increase amount of fluid
Formula component
Poor fluid intake
Drugs impaction
Diarrhea
Contamination of formula
Tube Feeding Nursing Calculations
ml in formula can = strength order
x
▪ Keep head of bed elevated
to 30- to 45-degree angle
▪ Have patient sit up on side
of bed or in chair
▪ Encourage ambulation
unless contraindicated
▪ Decrease rate or change
formula
▪ Check drugs that patient is
receiving, especially
antibiotics
▪ Take care to prevent
bacterial contamination of
formula and equipment.
amount and number of
feedings.
intake if appropriate
▪ Consult health provided to
change on formula to one
with more fiber content
▪ Obtain laxative order
▪ Increase fluid intake if not
contraindicated
▪ Give free water as well as
formula
▪ Check for drugs that may
be constipating
▪ Perform rectal
examinations to check and
manually remove feces if
present
▪ Refrigerate unused formula
and record date opened
▪ Discard outdated formula
every 24 hrs
▪ Discard formula left
standing for longer than
manufacturer’s guidelines
*8 hrs - ready-to-feed
formulas (can) *4 hrs -
reconstituted formula *24-
48 hrs - closed-system EF
▪ Use closed system to
prevent contamination
▪ Use sterile water for
flushes
DECELIS, G. P. 5
 NCM 116 – SKILLS LAB LECTURE NOTES
Suctioning: Oropharyngeal and Nasopharyngeal ▪ Hyperventilate client with 100% oxygen
• PURPOSE: To clear airways from before and after suctioning to prevent
mucus secretions hypoxia
1. Assess indications for suctioning: ▪ Allow 20-30 seconds interval between
➴ Audible secretions during respiration each suction to bring up mucous secretions
➴ Adventitious breath sound (auscultated) into the upper airways, and prevent
hypoxia
Pressure of suction equipment, to prevent
trauma to mucous membrane of airways ▪ Provide oral and nasal hygiene
Wall unit
Tracheobronchial Suctioning
Adult: 100-120 mmHg
▪ Client should be in semi- or high- Fowler’s
Child: 95-110 mmHg
position.
Infant: 50-95 mmHg ▪ Practice sterile technique. Use sterile
Portable Unit gloves, sterile suction catheter. To prevent
Adult: 10-15 mmHg infection
Child: 5-10 mmHg ▪ Hyperventilate client with 100% oxygen
Infant: 2-5 mm Hg before and after suctioning. To prevent
hypoxia
Position for suctioning ▪ Insert catheter with gloved hand (3-5
Conscious: Semi-fowler’s position inches length of catheter insertion). The
Unconscious: Lateral position trachea is 4 to 5 inches in length.
▪ Apply suction during withdrawal of
Appropriate size of sterile suction catheter, to catheter.
prevent trauma to mucous membrane airways ▪ When withdrawing catheter, rotate the
Adult: Fr. 12-18 catheter while applying intermittent
Child: Fr. 8-10 suction. To ensure adequate removal of
Infant: Fr. 5-8 mucus secretions.
▪ Suctioning should only take 5 to 10
NURSING INTERVENTION FOR seconds (maximum of 15 seconds). To
SUCTIONING prevent hypoxia, vagal stimulation and
▪ Don sterile gloves. Sterile technique prevents bleeding. Vagal stimulation causes
introduction of microorganism into the hypotension and bradycardia
respiratory tract. ▪ Evaluate: clear breath sounds on
▪ Length of catheter: measures from the tip of auscultation of the chest.
the client’s nose to the earlobe or about 13cm
(5 in) for an adult
▪ Lubricate catheter, to reduce friction:
o Nasopharyngeal suction tip-water
soluble lubricant
o Oropharyngeal suction tip-sterile water
on NSS
▪ Dispose contaminated equipment / articles
safely. To prevent contamination of the
environment.
o use one sterile suction catheter for each
episode of suctioning
▪ Assess effectiveness of suctioning
▪ Auscultate chest for clear breath sounds
▪ Document relevant data
▪ Apply suction during withdrawal of the
suction catheter (never during insertion) to
prevent trauma to the mucous membrane
▪ Apply suction for 5-10 seconds (maximum
15 seconds). Over suctioning causes
hypoxia and vagal stimulation

DECELIS, G. P. 6
 NCM 116 – SKILLS LAB LECTURE NOTES
Incomprehensible 2
PERCEPTION AND COORDINATION sounds
None 1
Extent of neurologic exam depends on:
• Chief complaint MOTOR RESPONSE
o reasons for seeking health care Obeys command 6
o Ano po ang inyong dahilan bakit Localizes pain 5
kayo nag pakunsulta? withdraws 4
• Physical condition Flexion/decortication 3
o Level of consciousness Extension/decerebration 2
o Ability to ambulate None 1
• Willingness of client
Examination of the neurologic system includes WHAT ARE THE PURPOSES OF GCS?
assessment of the following: • To address the three areas of neurologic
• Mental status including level of functioning
consciousness • To give an overview of the client's level
• Cranial nerves of functioning
• Reflexes • To evaluate the neurologic status of
• Motor function clients who have had a head or brain
• Sensory function injury

MENTAL STATUS PROCEDURE:

• Language- aphasia (language disorder) • Prepare the needed materials
• Orientation person, place, time, and self; o Chart
disorientation and confusion o ballpen/ pen
• Memory- recall of information o clean gloves
• Attention span and calculation-client's o hand washing materials
ability to focus • Perform hand hygiene and observe other
• Level of Consciousness- Glasgow Coma appropriate infection procedure (e.g.,
Scale clean gloves)
• Explain the procedure to the client and/or
WHAT IS A GLASGOW COMA SCALE? significant other/s.
• It is a tool to determine the level of • EYE OPENING
consciousness of an individual o Observe if the client’s eye opens
spontaneously. If the patient opens
o Perfect score – 15 – alert and his eyes spontaneously without
completely oriented external stimulation, 4 points are
o Lowest score – 3 given
o Call the client using his preferred
WHAT ARE THE COMPONENTS OF A GCS? name. Speak gently, shout if no
• Eye Opening – 4 points response. If the patient is sleeping
• Verbal Response – 5 points with his eyes closed, but opens his
• Motor Response – 6 points eyes with verbal command, 3 points
are given
EYE OPENING o Use a pen or pencil to exert pressure
Spontaneous 4 on the finger nail bed.
To speech 3 o Apply sternal rub. Use knuckles
To pain 2 gently by rubbing the middle of the
none 1 patient’s sternum as if you are
grinding a pill
VERBAL RESPONSE o Do trapezius squeeze by gently
pinching the shoulder
Oriented 5
▪ If the patient opens his eyes to
Disoriented 4
painful stimuli, 2 points are
Inappropriate words 3
given

DECELIS, G. P. 7
 NCM 116 – SKILLS LAB LECTURE NOTES
▪ If the patient does not open eyes
despite a painful stimuli, 1 point
is given
• VERBAL RESPONSE
o Ask simple questions like their name,
where they are and the month.
▪ If the client is able to answer the
three questions correctly, 5
points are given
▪ If the client speaks in phrases,
confused and disoriented, 4 • 7 BELOW – IN COMA
points are given • 3 – IN DEEP COMA
▪ If the client is uttering only one • AN EYE OPENING IS NOT ALWAYS
or two irrelevant words, 3 points A NEUROLOGIC IMPLICATION
are given
▪ If the client is moaning or
groaning, 2 points are given
▪ If there is no verbal response, 1
point is given
• MOTOR RESPONSE
o Ask the client to lift both arms
o Ask the client to lift both legs
▪ If the client is able to move his
arms and legs and follows
commands, 6 points are given
o Use a pen or pencil to exert pressure
on the patient’s finger nail bed
o Apply sternal rub. Use knuckles
gently by rubbing the middle of the
patient’s sternum as if you are
grinding a pill
o Do trapezius squeeze by gently
pinching the shoulder
▪ If client localises and tries to
push away this stimulus, this is
recorded as localising, 5 points
are given
▪ If the client pulls away from the
stimulating part, 4 points are
given
▪ If the client shows abnormal
flexion, like decorticate
posturing, 3 points are given
▪ If the client shows abnormal
extension, like decerebrate
posturing, 2 points are given
▪ If the client presents no motor
response even to painful stimuli,
1 point is given

DECELIS, G. P. 8
 NCM 116 – SKILLS LAB LECTURE NOTES
How is parenteral nutrition administered?
In external catheter, the nurse will attach the
PARENTERAL NUTRITION external end to another tube that connects to the
Definition: Often IV bag with the nutrition solution.
TWO TYPES OF PARENTERAL NUTRITION In internal catheter, attach the IV bag to a tube
1.PARTIAL PARENTERAL NUTRTITION connected to a special needle (called a Huber
(PPN) needle) that inserts into the implanted port.
• Given to supplement other kinds of The parenteral nutrition infusion takes about 10
feeding. The person can eat and yet still to 12 hours to fully transfer from the IV bag into
have malnutrition, partial parenteral the body. You may chose
nutrition
TYPE OF TPN BASED ON VEIN USED TO
DELIVER THE NUTRITION
• Central parenteral nutrition (CPN)
o Delivered through a central vein
– superior vena cava located
under the collarbone and goes
directly to you heart. The larger
central vein allows a larger
catheter to deliver higher
concentrations of nutrition with
higher calories. For this reason,
CPN is used to deliver total
parenteral nutrition.
• Peripheral parenteral nutrition (PPN)
o Delivered through a smaller,
peripheral vein, in neck or in one
of limbs.
o Used to provide partial
parenteral nutrition temporarily,
using the quicker and easier
access of the peripheral vein.

Side notes:
• Phlebitis – inflammation of vein
• Signs and symptoms: pain, swelling in the
affected area, redness, tenderness
• Pneumothorax – collapsed lung. Occurs
when air leaks into the space between
your lungs and chest wall.
• Sepsis – infection
• Air embolism
o Cause of wrong manner of
priming of the tubing

DECELIS, G. P. 9
 NCM 116 – SKILLS LAB LECTURE NOTES
o Clamp the tubing para di
magflow yung air
Valsalva manuever – pag-iri
Procedure:
1. Hand hygiene
2. Verify order and compare to label of
solution
3. Inspect 2: 1 CPN solution for particulate
matter; inspect 3: 1 CPN solution for
separation of solution.
NOTE: Do not use CPN solution if it has
coalesced (thick dense layer of fat droplets as
surface, appearing 10cm (4 inches) in thickness)
or oiled out (fat droplets separate from solution
that appear as a clear layer at surface) or appears
abnormal in any way. Notify the pharmacy and
request a new solution
4. Identify the Patient
5. Clean Gloves
6. Attach appropriate filter to IV tubing.
Prime tubing with CPN solution, making
sure that no air bubbles remain, and turn off
flow with roller clamp. Connect end of the
tubing to appropriate port of central
catheter and label port. Open roller clamp
to rate that maintains patency of line.
7. Place IV tubing into IV infusion pump,
open roller clamp completely, and regulate
flow rate on pump as ordered. In some
agencies, Infusion rate is immediately set
at the ordered rate. In other agencies an
initial rate of 40 to 60 mL/hr is established,
and the rate is gradually increased until
patient’s nutritional needs are supplied
(refer to agency policy)
8. DO not interrupt PN infusion (e.g.,during
showers, transport to procedure, blood
transfusion) and be sure that rate does not
exceed ordered rate
9. Change infusing tubing and filter using
strict aseptic technique Change IV
10. Administration sets for CPN every 24hrs
and immediately on suspected
11. Discard used supplies and perform hand
hygiene
RISKS OR COMPLICATIONS OF TPN
▪ Infection- bacteria from the IV catheter
can infect the bloodstream. If the
infection spreads throughout the body,
it can lead to sepsis, a life-threatening
complication
▪ Blood clots can form at the site where
the catheter meets the vein
▪ GI atrophy can begin to occur after
about two weeks. GI function usually
returns gradually
▪ Glucose Imbalances (Hyperglycemia
or hypoglycemia) are common. These
treated with insulin and dextrose
adjustments
DECELIS, G. P. 10
 NCM 116 – SKILLS LAB LECTURE NOTES
▪ Transient Liver reactions to the
nutritional formula can occur. Can be
managed by adjusting their formula.
▪ Parenteral Nutrition-Associated Liver
Disease (PNALD) is complication of
long-term parenteral nutrition. Liver
disease affects up to 50% of patients
after the five to seven years. In
premature infants, it may be because
their liver isn’t fully developed. In
adults, it might be related to the
diminished gut bacteria that results
when the gut isn’t being used.
▪ Gallbladder Problems can result when
the of stimulation from the digestive
system causes bile to accumulate
without being released normally into
the small intestine. The nurse may be
able to stimulate gallbladder
contractions by varying your formula
and encouraging at least a small
amount of oral feedinggBone
Demineralization (osteoporosis or
osteomalacia can develop in people
who receive long term parenteral
nutrition, possibly due to vitamin and
mineral deficiencies (Calcium,
magnesium and Vitamin D)
Other possible complications include:
• Injury during the insertion of the
catheter
• Fluid overload
• Reactions to lipid emulsions in the
formula due to food allergies “Hunger
pangs”
What is the nurse’s responsibilities in
administering TPN?
• Educate client on the need for and use
of TPN
• Apply knowledge of nursing procedure
and psychomotor skills when caring for
a client receiving TPN
• Apply knowledge of client
pathophysiology and mathematics to
TPN interventions
• Administer parenteral nutrition and
evaluate client response (e.g., TPN)
• Care for a patient with TPN
• Keep the dressing over the catheter exit
site clean and dry
• Flush the catheter with saline or
heparin as directed
• Wipe at injection sites with alcohol
• Be sure all IV supplies are in sealed,
sterile packets
• Check the label on the TPN bag before
starting an infusion. Make sure your
name is on it.
• Check that the TPN fluids and dose are
correct
• Don’t use TPN with an expired date
• Don’t use TPN if the bag is leaking
• Don’t use TPN if it looks cloudy,
lumpy or oily
• Don’t use TPN if has particles floating
in it
• Handle supplies as directed Store TPN
in the refrigerator. Don’t freeze
• Before using TPN, let it get close to
room temperature. Take it out of the
refrigerator 1 hour before use. Don’t
heat
• If vitamins or minerals need to be
added to the TPN, do so as directed.
• Put all used needles and syringes in a
special container (sharps container)
• When the infusion is done, put the used
supplies in a plastic bag. Seal the bag
and throw it in the trash
• Track Your Health
• Weigh daily. If you lose or gain weight,
tell the healthcare provider. TPN dose
may need adjusting
• Keep track of the urine output as
directed. Tell the nurse if the amount
increases or decreases a lot
• Check the blood sugar if directed.
Healthcare provider may take a blood
sample weekly. This is to make sure the
TPN dose is right for you
• Know this IV basics
• Keep the dressing over the catheter exit
site clean and dry. Change the dressing
as directed if it comes loose or gets
soiled or wet
• Flush the catheter with saline or
heparin as directed
• Wipe all injection sites with alcohol
• Be sure all Iv supplies are in sealed,
sterile packets. If sterile packets are
open, throw away those supplies
• Don’t stop the pump or change settings
during an IV infusion unless your
healthcare provider tells you to do so
• Call 911 if you have chest or trouble
breathing
DECELIS, G. P. 11
 NCM 116 – SKILLS LAB LECTURE NOTES
Body Mass Index Computation and Calculation: 73 ÷ (1.73) x 2
Interpretation = 24.41
Body mass Index (BMI) is a measure of body fat How is BMI Calculated?
based on height and weight that applies to adult • BMI is a number calculated from a
men and women, person’s height and weight
Anthropometric Measurements for nutrition
assessment includes • Formula: Weight (lb) / [Height (in)2] =
Height (ht) x 703
Weight (wt)- the best indicator of nutritional
statues of an individual • Example: Weight = 150 lbs, height =
Skin folds- fay folds 5’5” (65”)
Arm muscle Circumference (AMC)
BMI FORMULA: Calculation: [150 ÷ (65)2] x 703 = 24.96
USA
BMI= 703 x weight (lb) BMI Interpretation Categories
Height (in2) < 18.5 Underweight

METRIC 18,5 - <24.9 Normal

BMI= weight (kg)
Height2 (m2) 25 – 29.9 Overweight
Calculate BMI (Using Metric Measurement)
Example 1: 30 or higher Obese

Height: 152 centimeters= 1.52 meters 30 – 34.9 Mild Obesity (Class1)

Square of height: (1.52 x 1.52) m 2
=2.31 m2 35-40 Moderate Obesity
Weight: 60 Kilograms (Class 2)
BMI= weight = 60_ = 25. 96 Above 40 Severe Obesity (Class
Height2 2.31 3)
Example 2:
If your weight is 198 lb B. ENEMA
a. To relieve constipation and fecal
And, if your height is 70 inches impaction
b. To relieve flatulence
Calculate: c. To administer medication
BMI= 703 x 198 = 28.4 d. To evacuate feces in preparation for
702 diagnostic procedure or surgery
Position:
BMI Value Meaning • Adult: Left side-lying/ Left-sim’s
Less than 18.5 Thin • Infant: Dorsal Recumbent
18.6 to 24.9 Healthy Management: Clamp, Restart at slower Rate
25 to 29.9 Overweight WOF: Abdominal Cramping- Too Rapid enema.
More than 30 Obese Lowe the solution
Less than 18.5 Thin
18.6 to 24.9 Healthy
25 to 29.9 Overweight
More than 30 Obese

Body Mass Index

• Formula:
• Weight (Kg) ÷ Height (M)2
• Example:
• Height = 173cm (1.73 m) Weight = 73
kg

DECELIS, G. P. 12
 NCM 116 – SKILLS LAB LECTURE NOTES
TYPES OF ENEMA
Cleansing Enema a. High Enema
Stimulates peristalsis by irritating the colon and To clean as much of the colon as possible; 1000 mLs
rectum and or by distending the intestine with of solution is introduced to an adult.
the volume of fluid introduced. b. Low Enema
To clean the rectum and the sigmoid colon only;
500mLs of solution is introduced to an adult.
Carminative Enema
To expel flatus 60-180mLs of fluid is
introduced.
Retention Enema
Introduces oil into the rectum and sigmoid
colon; dilute retained in 1 to 3 hours. Acts to
soften the feces and to lubricate the rectum and
the anal canal, facilitating passage of feces.
RETURN FLOW ENEMA/ HARRIS FLUSH/ The solution container is lowered so that the fluid
COLONIC IRRIGATION backs out through the rectal tube into the container
300- 500mL of fluids The inflow-outflow process is repeated 5-6 times
Replace the solution several times during the
procedure as it becomes thick with feces
This procedure may take 15-20 minutes to be
effective

Non-Retention Enema Retention Enema

Purpose CLEANSING THERAPEUTIC PURPOSE
Example 500- 100 ml tap water Carminative Enema

Soap suds ml of castile soap in 500- 1000mL of

water

Normal Saline Solution (9mL of NaCl to

1000mL of water)

Hypertonic Solution/ Feet enema (90-120 mL)

COMMERCIALLY AVAILABLE
Height of the 18 Inches 12 Inches
Solution
Temp of the 115-125 F 105-110 F
Solution
Duration (Time of 5-10 mins 2-3 Hrs
the Retention)

1. Check the doctor’s order 9. Introduce solution slowly

2. Provide privacy 10. Change the position to distribute solution
3. Promote relaxation well in the colon (High Enema); If low
4. Position the client: enema, remain in left lateral position
• Adult- Left Lateral Position 11. If the order is cleansing enema
• Infant/ Small Children- Dorsal • Give enema 3x
Recumbent position • Alternate hypotonic solution with isotonic
5. Sizes of rectal tube to be used are as solution to prevent water intoxication or
follows: hyposmolar fluid imbalance
• Adult: Fr. 22-32 • If abdominal cramps occur during
• Children; Fr. 14r. 14-18 introduction of solution, temporarily stop
• Infant: Fr 12

DECELIS, G. P. 13
 NCM 116 – SKILLS LAB LECTURE NOTES
6. Lubricate 5 cm (2 in) of the rectal
tube
7. Allow solution to flow through the
connecting tubing and rectal tube to
expel air before insertion of recta;
tube
8. Insert 7-10 cm (3-43-4 in) of rectal
tube gently in rotating motion. To
prevent irritation of anal and rectal
tissues.
Siphoningng an Enema (If non-retention
enema solution is retained)
• Use water at 40oC (105 F)
• Client in the right side-lying position
• Height of the enema container: 10cm
(44 in) above the anus
• Quickly lower enema container after
Introduction of solution
• Note amount of fluid siphoned off as
well as color, odor and presence of any
feces or abnormal constituents such as
blood or mucus.
BLOOD GLUCOSE TESTING
“Diabetes is a major cause of blindness, kidney
failure, heart attacks, stroke and Tower limb
amputation.”
-World Health Organization
Diabetes Management-UIH Pediatric
Endocrinology
https://www.youtube.com/watch?v=XZW30ljB
w1g
Purpose:
• To measure the amount of glucose
present in the patient’s blood.
• To monitor the blood glucose levels of
a patient.
• To determine the need to adjust the
diet, exercise or medications of the
patient.
• To screen for diabetes mellitus.
Precautions
• Note on the laboratory request when the
patient last ate, the collection time, and
when the last dose of insulin or oral
antidiabetic drug was given.
PREDIABETES
• Before people develop type 2 diabetes,
they almost always have "prediabetes"-
blood sugar levels that are higher than
the flow of solution by clamping the tube
until peristalsis relaxes.
• After introduction of the solution, press
buttocks together to inhibit the urge to
defecate
• Ask the client who is using the toilet not to
flush it. The nurse observes the return flow
• Do perineal care
• Make relevant documentation
Patient Preparation:
• Explain to the patient that the fasting
blood glucose test is used to detect
disorders of glucose metabolism and aids
in diagnosis of diabetes mellitus.
• Inform the patient that the test requires a
blood sample. Explain who will perform
the venipuncture and when.
• Explain to the patient that he may
experience slight discomfort from the
tourniquet and needle puncture.
• For fasting blood glucose, instruct the
patient to fast for at least 8 hours before
the test.
• Notify the physician of medications the
patient is taking that may affect test
results.
• Alert the patient to the symptoms of
hypoglycemia (weakness, restlessness.
nervousness, hunger and sweating) and
tell them to report such symptoms
immediately.
PROCEDURE AND POST-TEST CARE
During the Test
• Properly collect the sample.
• Apply direct pressure to the venipuncture
site until bleeding stops.
Post Test
• Provide a balanced meal or snack after the
test.
• Instruct the patient that he may resume his
usual medications as ordered.
normal but not yet high enough to be
diagnosed as diabetes.
• Physicians sometimes refer to prediabetes
as impaired glucose tolerance (IGT) or
impaired fasting glucose (IFG),
depending on what test was used when it
was detected.
REFERENCE VALUES
A1C/ glycosylated hemoglobin test
DECELIS, G. P. 14
 NCM 116 – SKILLS LAB LECTURE NOTES
• The AlC test measures the average blood
sugar for the past two to three months.
• Diabetes is diagnosed at an A1C of greater IN SUMMARY
than or equal to 6.5% Result A1C Fasti Glucos Rando
ng e m
Result A1C Bloo Toleran Blood
d ce Test Sugar
Normal Less than 5.7% Suga Test
r Test
Prediabetes 5.7% to 6.4% Diabetes 6.5 126 200 200
or mg/ mg/ dL mg/
Diabetes 6.5 or higher high dL or or dL or
er highe higher higher
r
Fasting Blood Glucose/ Fasting Plasma
Glucose/ Fasting Blood Sugar Prediabe 5.7 100 140 to N/A
• This test checks the fasting blood sugar tes % to to 199
levels. Fasting means after not having 6.4 125 mg/dL.
anything to eat or drink (except water) for % mg/d
at least B hours before the test. L

Result Fasting Plasma Glucose Normal Less Less Less N/A

than than than
Normal Less than 100 mg/dL 5.7 100 140
% mg/d mg/dl.
Prediabetes 100 to 125 mg/dL L

Diabetes 126 mg/ dL or higher

Abnormal Findings:
• Confirmation of diabetes mellitus requires
Oral Glucose Tolerance Test(OGTT) fasting plasma glucose levels of 126
• The OGTT Is a two hour test that checks mg/dL or more obtained on two or more
your blood sugar levels before and two occasions.
hours after you drink a special sweet • Increased fasting plasma glucose levels
drink, it tells the doctor how your body can also result from pancreatitis, recent
processes sugar acute illness.
• Low plasma glucose levels can result
Result OGTT from malabsorption syndrome and some
cases of hepatic insufficiency.
Normal Less than 140 mg/dl.
How to treat Low Blood Glucose?
Prediabetes 140 to 199 mg/dL. • If blood sugar is lower than 70 mg/dL, the
patient should do one of the following
Diabetes 200 mg/ dL or higher immediately:
o Take glucose tablets
Random Plasma Glucose Test/ Random Blood o Drink four ounces of fruit juice
Sugar o Drink four ounces of regular soda,
• This test is a blood check at any time of not diet soda
the day when the patient nave severe o Eat four pieces of hard candy
diabetes symptoms
Interfering Factors
Result Random Plasma Glucose • Recent illness, infection, pregnancy
• Large doses of thiazide diuretics
Diabetes 200 mg/ dL or higher • Alcohol. B-adrenergic blockers, insulin
and oral anti-diabetic agents.

DECELIS, G. P. 15
 NCM 116 – SKILLS LAB LECTURE NOTES
CAPILLARY BLOOD GLUCOSE TEST
Definition:
• A method of blood glucose testing in
which the patient pricks his or her finger
and applies a drop of blood to a test strip
that is read by a meter.
• Was developed to replace glucose testing
by patients or by the staff in clinics. CBG
testing can also be applied in the hospital
laboratory as a cost-effective method to
rapidly test blood glucose levels.
WHEN SHOULD PATIENTS CHECK
THEIR BLOOD GLUCOSE?
• How often they check their blood sugar
depends on the type of diabetes they have
and if they take any diabetes medicines.
• Typical times to check your blood sugar
include:
o When you first wake up, before you
eat or drink anything.
o Before a meal.
o Two hours after a meal.
o At bedtime.
WHAT CAUSES LOW BLOOD GLUCOSE?
• Low blood sugar (also called
hypoglycemia) has many causes,
including missing a meal, taking too much
insulin, taking other diabetes medicines,
exercising more than normal, and
drinking alcohol.
• Blood sugar below 70 mg/dL is
considered low.
• Signs of low blood sugar are different for
everyone.
• Common symptoms include:
o Shaking
o Sweating
o Nervousness or anxiety
o Irritability or confusion
o Dizziness
o Hunger
HOW TO TREAT LOW BLOOD
GLUCOSE?
• If blood sugar is lower than 70 mg/dL, the
patient should do one of the following
immediately:
o Take glucose tablets
o Drink four ounces of fruit juice
o Drink four ounces of regular soda.
not diet soda
o Eat four pieces of hard candy
• Wait for 15 minutes and then check the
blood sugar again. Do one of the above
treatments again until your blood sugar is
70 mg/dL or above and eat a snack if the
next meal is an hour or more away
Step-by-step Procedure
1. States the definition of CBG test.
2. States the purposes of CBG testing.
3. States correctly the procedure and
rationale for each action.
4. Verifies the doctor's order
• Promotes accuracy and safety in
performing the procedure
5. Prepares the materials needed.
• To ensure a smooth flow of the
procedure.
6. Explains the procedure to the client and
instruct the need for monitoring blood
glucose
• To minimize anxiety and gain the
patient's instruct the need for
monitoring blood cooperation for
the procedure.
7. Washes hands before the procedure.
Don gloves.
• To prevent cross infection and
contamination of equipment and
surfaces.
8. Prepares the lancet.
• Using a new and sharp lancet will
ensure pricking
9. Removes the test strip from the
container. Recap the container
immediately.
• Prevents the strip from coming in
contact with dust and moisture
which may affect the accuracy of
the reading
10. Turns monitor on. Check the code
number on monitor screen.
• Some meters may require
calibration and adjustment.
11. Insert the test strip into the glucometer
according to the direction specified in
the device
• To prepare the glucometer for the
test.
12. Massages side of finger toward the
puncture site
• Promotes blood flow to the site of
puncture.
13. Cleanse area with alcohol. Dry
thoroughly.
DECELIS, G. P. 16
 NCM 116 – SKILLS LAB LECTURE NOTES
• Ensures asepsis during the
procedure.
14. Holds the lancet perpendicular to the
skin and prick the puncture site with
lancet.
• Ensures collection of blood needed
for the test.
15. Wipes away the first drop of blood with
The first drop of blood may contain
serous cotton balls (if recommended).
• The first drop of blood may contain
serous fluids and may result to
inaccurate reading.
16. Lightly squeeze the puncture site until
a hanging drop of blood has formed.
• Ensures collection of blood needed
for the test.
17. Touches the drop of blood to pad or test
strip without smearing it.
• Smearing may alter the test result.
18. Applies pressure to puncture site with
cotton ball.
• Prevents bleeding at the site.
19. Reads blood glucose result and
document appropriately.
• Ensures proper documentation.
20. Turns the meter off, dispose of supplies
appropriately, and discard the lancet in
the sharp container.
• Prevents contamination of the
equipment and accidental injury
from sharps.
21. Removes gloves and perform hand
hygiene
• Reduces transmission of
microorganisms.
22. Records blood glucose result on chart.
• Ensures proper documentation.
23. Reports abnormal result to the
physician.
• Results will determine the
treatment plan for the patient.

DECELIS, G. P. 17