veer ee conde ee inal Instructor Evaluator: eee oo. SKILL11-2 Inserting a Nasogastric (NG) Tube ‘Goat The tube Is passed into the patients stomach without any complications 1. Very the medical order for insertion of a NG tube | 2 Perform nand hygiene and put on PPE, indicated J a. tdentiy ure patie = — | 4 xotain the procedure tote patienand provide the rationale as 10 why the tue is needed. Discuss the assoc ated discomforts that may be experienced. and possible Interventions that may ally thi discomfort. Answer any ‘questions as needed, | 5. Gather equipment, nein selection ofthe appropriate NG tube, 6 Close the patient bedside curtain oF door. Raise ed vo a comfortable working positon usualy elbow height of tae ‘categiver(VISN 8, 2009) Aas the patient to igh Fowler's position or elevate the head ofthe Bed 45 depres ithe Patients unable to maintain upright positon. Drape chest ‘with bath twa or disposable pd. Have emesis basin and issues handy. —— | 7Heasure the distance to tnsert tube by placing tp of tube atpatient’s nestril and extending tp of earlobe and ‘then C0 lp of xiphoidprecessMark tube with an indelible marker. ___ | 8, puton gloves Labricate tip oftube (at east 2-4) with water-soluble lubricant Apply topical anesthetic to nostri land oropharyne, as appropriate | 9. aner selecting the appropriate nostril ask patient to | \ Sigh lex hea bark against the pllow. Gently insert the tube into the nostri while directing te tbe upward and bockward along thelr ofthe nose Patient may gag When tae reaches pharyne Provide tissues for tearing or ‘watering of eyes, Offer comfort and reassurance to the patient. ECU Rees etnies One ara | TNESERNEE SSS cere oe ring Ce Cie ary Sepee et soe Es excellent Satisfactory Needs Practice ‘SKILL 11-2, Inserting & Nasogastric (NG) Tube (Continued) Comments 420, When pharyn Is tached, Instruct patient to touch chin to chest. Encourage patent to sip water though a straw oF ‘wallow even pou are permited. Advance tbe tn ‘ownvrard and backward direction when patient swallows ‘Stop when patent breathes.’ gagging and coughing per st, stop advancing the tube and check placement of tube with tongue blade and flasiigheit whe is curled, ‘ralghten he tabe and atempt to advance again Keep ‘uvancng tbe unt pen marking is eached. Do mot use force. Rotate tube tft meets resistance. 14 Discontinue procedure and remove tube if there are signsof dstress, sich as gasping, coughing, ganosis, and ‘nab to speak or hum, : 12, Secure the tube loosely to the nose or cheek unt is Getermine thatthe tube is in the patents stomachs a Attach syringe to end of tube and aspirate a small amount of stomach contents ‘Measure the pl of aspirated uid using pl paper or a meter, Place a drop of gastric secretions onto pH paper tr place small amount in plastic cup and dip the pl ‘paper into Within 30 seconds, compare the color on ‘the paper with the chart supplied by the manufacturer. Visualize aspirated content, checking fr color and consistency, 4. Obtain radiograph (tray) of placement of tbe, based ‘on faclity policy (and ordered by physician). 13. Apply skin barrier to Up and end of nose and allow to Ary. Remove gloves and secure tube with a commercially repared device (fallow manulacturer‘sdrections) or tape tw patients nose. To secure with tape: ‘Cut a piece of tape and split bottom 2 oF use pack aged nose tape for NG tubes. ». Place unspit end over bridge of patient's nose, ‘€ Wrap split ens under bing and up and aver onto nose. Be careful et to pull tube too tightly against 14, Puton gloves. lamp tube and remove the syringe. Cap the tube o attach tube to suction according to the medical orders (se Chapter 13) ‘asin Cis x Chil Nr Side —_——a ee ee en ne ee en ee ee Excellent satefactory SKILL 11-2 27 See EE Ee ees Inserting a Nasogastric (NG) Tube (Continued) 15, Measure length of expos tube Relnforce markingon tube at nostril with indelibie ink. Ask the patient to tur thelr head the sie opposte the nostri the tube i inserted Secure tube to pation’ gown by using rubber band or tape and safety pn. For additonal support tube canbe taped ‘onto patients cheekusinga piece oftape Ifa double-lumen tube (eg Solem sump) is used secure vent above stomach leveLAttch at shoulder lve, 116, Assist with provide ora hysiene at2-to 4-hour intervals. Lubricate the lis generously and clean nares and lubricate asneoded. Offer analgesic throat lozenges or anesthetic spray for throat iia if needed. 17, Remove equipment nd return patient toa position of comfort Remove gloves Raise side rll and lower bed. 18, Remove additional PP, bused, Perform hand hygiene—l as ae te Year Level, Grade Instructor Evaluator. ‘SKILL 11-3, Administering a Tube Feeding —_ ed ‘Goak:The patent reels the tube feeding without complaints of nausea oF episodes of vomtng. Comments i | & Assomte equipment check amount, concentration, type, “and frequency of tube feeding on patents chart. Check ‘expiration date of formula, 2, Perform hand byglene and put on PPE, Indicated. 3. Kdentfy ene patient. nas | 4 explain the procedure tothe patient and why this Intervention is needed. Answer, any questions as heeded 5. Assemble equipment on overbed table within reach. | = =} 6 clase the patients bedside curtain or door, Raise bed to ‘comfortable working position, usually elbow height of the caregiver (VISN 8, 2009). Perform key abdominal assessments as deseribed above, | 7 Pasition patient with head of bed elevated at least 30 to 45 degrees or as near normal pesition for eating as possible. £8. Puton gloves. Unpin tube from patient's gown. Verify the position of the maricing on the tube at the nostril. Measure Tength of exposed tube and compare with the documented Tength, 9. Attach syringe to end of tube and aspirate a small amount ‘of stomach contents, as described in Skill 11-2, 10. Check the plas described in Skill 11-2 11, Visualize aspirated contents, checking for color and consistency IU iis not possible to aspirate contents: assessments to ‘check placement are inconclusive; the exposed tube length hhas changed; or there are any other indications that the tube is not in place, check placement by x-ray. ‘Alier multiple steps have been taken to ensure thatthe feeding tubes located in the stomach or small intestine, ‘aspirate allgastrc contents withthe syringe and measure tocheck for the residual amount of feeding in the stomach. ‘Return the residualbased on facility policy, Proceed with feeding it amount of residual does not exceed agency policy nicated in the medical recon fr the lit239 SKILL 113 i ——Atitstering aTube Feeding (Continued) Comments | 14 Flash tube with 30 mb of water for irrigation, Disconnect ‘tinge from tubing and eap end of wing while preparing the formula feeding equipment. Remove gloves —— — — | 15.Puton gloves before preparing assembling and hancling any part of the feeding system. =] 16. Administer eeding © ‘When Using @ Feeding Bag (Open System) — — —_] atarernagand/ortbing with cate and ine Hanghagon "Wpdleandadjusttoabut 2 above the sonech Clamp tng — | © beneath expen apa oe rma Chanse 2p ‘of fed container th dsfecant before opea ng "Pour forma inn fasding bag and alow coton to run through ting Ge camp sey ates pl c. Attach feeding setup to feeding tube, open clamp, and | Teale rp woarngto he neica ere ordiow | feeling vo run ih ve 80 mates, | ee 30 60 mt 12 0) of water for rigatin to Ajeeding bog when fete I cles conplcel end tilow i Fun tagh the tube Clam tubing edly fer water has been eerie ss instilled, Disconnect feeding setup from feeding tube. lat tube andere end with exp. ose comes hot er ee ce low, by helght of the syringe. Do not push formula toning tothe patent even if te patient doesnot appear toe ait Reasute the patient you wil iterupe Drocedare i he or he indicates respiratery acu. 7, Adjustbed to comfortable working height usually elbow height ofthe carepver(VISN @ Patient Safety Center, 2009) Lower side ral closet to you. I patient is consctous place Im or her ina sem-Fowter's position. patient is uncon ‘Sclous place him oF her in the lateral position facing you. Move the bedside table cose to your worle aren and raise it eo waist height @, Place towel or waterproof pad across the patients chest. ‘Adjust sution to appropriate pressure. Fora wall unit fr adult: 100-120 mmm Hg Roman, £2005); neonates: 60-80 many Hg Infants: 60-100 mm Hg: ctuldren: 60-100 min He adolescents 60-120 mm Hig (ireton, 2007). For 2 portable unit for an adult: 10-15 em Hg; neonates: 6-8 cm Hg: Infants: 8-10 em Hg; children: &-10 em Hg Adolescents: 6-10 cm Hg ‘Put ona disposable, dean glove and occlude the end of ‘the connecting tubing to check suction pressure Place the ‘connecting tubing in 2 convenient location.i ‘SKILL 14-6 Suctioning the Nasopharyngeal and | Oropharyngeal Always (Continued) excellent Satisfactory Needs Practice comments poor open wrapper or container becomes a sterile eld to hold | ter suppis carefully remove the sterile container, | touching only the outside suri. SUP on the wor | surface and pour sterile saline into it 414, Plac a smal amount of water sluble brant on the ‘Sete ld, taking cae to aot touching tester eld wth the lorie package | 22 neraso he patient’ supplemental xygentevel or apply -upplemental oxygen pe act policy Or primary care provider order. | 13, putontace sie goggles and mask Put on strle | 7% Gloves. The daminant hand wil manipwlat the catheter | fand mustremain strle The nondorinant hand is fonsiderd clean rather than serie and wil control the ‘suction vale (Yor) onthe ntheter. ________ | 14. wie dominant goved hand, pick up sterile catheter. Pick ‘up the connecting tubing withthe nordomant hand and fonnec the tubing and suction catheter. | 15. oisten th exter by dipping tint the conan of Serie saline. Orlude Yue to check suction. __ __ __} 16. Encourage the patent to tke several deep breaths | 17, appt rian ote fst 2 wo 3 inches ofthe cate, {sng the lubricant ha was placed onthe tried | is Remove te agg delivery device appropriate. Do not | 1 dppb suction a the atheter is inserted, Hold the catheter between yur thumb and foreinger: nse he cater | for nasopharyngeal suclonnggenty insetaheter | Through was and along the Door of the nos toward the aceaRllthecaticter between your | fingers to elp advance vane the catheter approx rately 5106 to each te ary | — — —] 1 onesie sutin pages merece | | nsororopharyngea! suctinlnginsrtcatheter through he ‘mou along the sie ofthe uth toward the trachea “Advance the catheter 3041 each the pharyn (See the Sl Variation in your skl book for masotracheal suctioning) | 2o4ppiy suction by ttroienty occtung the ¥ port on the catheter withthe thumb of your nondominant hand land gently rotating the eathetras itis being withdrawn. | De no suction for more than 10 o 15 seconds ata ine, | Ces ree |e Benet ton fag ar Carers eg ee Chai Cle sar te296 excellent Satisfactory Needs Practice Seibel aS SKILL 146 suctioning the Nasopharyngeal and ‘Oropharyngeal Airways (Continued) Comments breaths ‘loves, cal Raise bed al 25.7 126, offer oral hye 28, Remove ada 24. Replace the oxygen delivery device using your nondominant hand ifappropriate, and 22, Fash catheter with sine. Assess ing and repeat, a8 needed, and acc ance. Wrap the ston ctl hand between attempts 23Allow atleast 30-second to 1-minute interval ‘additonal suctioning is needed. Nomore thom three “ction passes shoul be made per suctioning episode ‘ternate the nares, untesscontraindcate, i ‘uctioning ts equtredDo wot force the catheter through the nares Encourage ‘breathe between sictioning Seton the orpharys after Sucioning the nasopharyn 24, When suctioning is compl rant hand ove the tut Remove glove fom none eter, ad container wth solution i the appro> priate recep vamom suction Rerove supplemental oxygen placed fOr suctioning if appror od mask Perform hand hygiene, 239, Reawess patients respratry status, induding respiratory ie efor oxygen saturation, and lung sounds. have the patient take several dee? tectveness of suction: ding to paint’ ter inter around your dominant the patent to cough and deep {ted remove glves from dom! cole catheter, poling them off inside dominant band and dispose of Assist patient to a comfortable position. in pace bed inthe lowest postion. ate Remove face shld or goes Jene after suctioning ional PPE, lf usod.Porform hand hygiene. ing oct Clea Nun Sis297 Ramat es skier pe ES ease Instructor/Evaluator: Grade ‘SKILL 14-7. Inserting an Oropharyngeal Airway ‘Got The patient sustains a patent away. Comments — — | © ding necessary equipment tothe bedside stand or overbed table, — — | 2 Perform hand hygiene and put on PPE, indicated — | 3 tency the patient, —— | 4 close curtains around bed and cote the door tothe room, At possibie, — — —_| 5: txplain wo the patont what you are going to do nd the teason for ding I eventhough the patent dove act appear tobe alert | — | 6 Pucon aisposabe gloves puton goggles or fae shield, as sndieated 7. Measure the oropharyugeal airway for correct size. Measure the oropharyngeal airway by holding te sirway ‘on the side ofthe pases face. The airway should reach from the opening ofthe mouth tothe back ange ofthe aw. | check mouth for any loose teeth, dentures or other {forelgn materia Remove dencures or material J present 9 Position patient in seml-Fowler's poston | = = } 10. suction patent if necessary. 14, Open patient's mouth by using your thu and index in igerto gently pry teeth apart Insert the airway with the ‘curved tip pointing up toward the roof ofthe mouth 12, Slide the alway across the tongue to the back ofthe mouth Rotate thealrway 180 degrees ast passes the uvula. The tip should point down and the curvature should follow the con tour ofthe roof ofthe mouth. A Mashight can be used to confirm te postion ofthe airway with the curve fing ‘over the tongue. 12, Ensure aceurate placement and adequate ventilation by | auscultating breath sounds | —-$-"ses8 w@ee eee ees | | - —- — | | | sng Checklists Cia Nursing Shits eda a SKILL 14-7 Inserting an Oropharyngeal Airway (Continued) 114 Postion patent on his or her side when airway itn place 15, Remove gloves and adltional PP, if used. Perform hand iygene ‘* 116. Remove the alway fora brief period every 4 hours oF according to faiity pole, Assess mouth, provide mouth ‘ate and clean the sirway according to fact policy before reinsertng i. Pe Sires Ge roe] Ning Chek Cia Nursing Ske