Inserting a Nasogastric Tube

Assessment:

Check the physician’s orders. Assess the patient’s capabilities for cooperating with the procedure. Determine where the needed equipment is located.

Planning:

Wash your hands. Gather the equipment, as follows: Stethoscope, restraint or hand mitts (for infant or small children), asepto syringe, tongue balde, sterile disposable gloves, water soluble lubricant, tissues, glass of water with drinking, straw, kidney basin, nasogastric tube- appropriate size, adhesive tapes, safety pin and towel. Before insertinga nasogastric tube determine the size of tube to be inserted and whether or not the tube is to be attached to a suction. If it is necessary, plan for any assistance.

Implementation:

Identify the patient. Explain the procedure to the patient and why it is needed. Place the patient in high fowler’s position if possible. Put a clean towel over the patient’s chest to protect the linen. Prepare nose skin for tape. Put on gloves. Determine how far to insert the tube. Use the tube to mark off the distance from the tip of the client’s nose to the tip of the earlobe and then from the tip of the earlobe to the tip of the sternum. Mark the tube with a piece of tape. Lubricate the tube with a water-soluble lubricant. Lubricate the portion of the tube from tip to marking. Flex the patient’s head slightly forward. Have a basin in the patient’s lap and tissues handy. If orders allow, have the patient sip water and swallow while you gently but steadily advance the tube. There may be some temporary gagging, caused by the gag reflex, but this should subside as the tube is progressed. Using tape, secure the tube in the patient’s nose. Check to see if the end of the tube in the stomach. If it is curled in the back of the throat, it is uncomfortable and ineffective. You can easily check this by asking the patient to open the mouth or by holding down the tongue with a tongue depressor. Using a flashlight, you can see if the tube is curled in the  back of the throat. You can check the tube’s position in several ways, some are more reliable than others. Keep the free end of the tube plugged at all times except when checking position, feeding, or irritating. Secure tubing’s using adhesive tapes. Coil free end and pin to the clothing. Help the patient to a comfortable position. Provide frequent oronasal care. Dispose of gloves, and wash your hands.

Evaluation:

Evaluate using the following criteria: Patient comfortable, No irritation at nostrils, Normal breathing rate and rhythm, No indications of nausea or regurgitation, Tube properly placed.

Documentation:

Initiate an intake and output patient record. Document the following on the patient record: Type and size of the tube inserted, Amount and characteristics of any drainage returned. Patient response to the procedure. Add to the Nursing care plan information pertinent to care needed.

Nasogastric Tube Feeding

Assessment:

Check the physician’s order. Read any observations about previous feeding noted on the patient’s chart. Wash your hands.

Planning:

Gather any equipment you will need, as follows: Feeding formula-warm is indicated, drinking water, stethoscope and towel.

Implementation:

Identify the patient. Explain what you are going to do. Place the patient in semi-fowler’s position. Drape chest with towel. Test the placement of the tube and for residual formula. Asepto syringe method. When you use this method, hold the syringe manually, and fill and refill. Again, do not allow the water or formula to fall below the narrowing at the bottom of the syringe. Flush with prescribed amount of water.  Use gravity flow to move the formula through the tube. If the flow slows down or stops, gentle pressure on the asepto bulb or ”milking” the tubing may help. If the patient gags during the feeding, stop the procedure. After the feeding, clamo the tube or plug it. Reposition the patient in low or semi-fowler’s position. If the patient is comatose, the head should be turned to one side. Wash your hands.

Evaluation:

Return to the patient in approximately 30 minutes.

Documentation:

Record on the medication sheet or progress notes. Your notes should indicate the date, time,  type, and amount of formula, amount of water and patient’s response.

Removing a Nasogastric Tube

Assessment:

Verify that the tube is no longer needed and that the physician has ordered the removal. Check the physician’s order.

Planning:

Wash your hands. Obtain paper. Gather all materials needed, as follows: Clean gloves, Paper towels, towel and Oral hygiene tray.

Implementation:

Identify the patient. Explain to the patient that although removing the tube will be uncomfortable, it will be over quickly. Drape patients with a towel. If suction is operating, turn it off, and disconnect the tube. Put on gloves, and pinch the tube closed or plug it. Withdraw the tube smoothly in a continuous motion. Place the soiled tubing in the paper towel and cover it. Provide comfort, and give mouth care. Measure secretions in the collection container. Dispose of the equipment and gloves properly. Wash your hands.

Evaluation:

Evaluate using the following criteria; patient comfortable,and no abdominal distention present.

Documentation:

Document the time the tube was removed, the amount and description of material in the collection container, and the patient’s response to the procedure.

Providing Perineal-Genital Care: Male

Assessment:

Assess for the presence of irritation, excoriation, inflammation or swelling, excessive discharge, odor, pain or discomfort, urinary or fecal incontinence, recent rectal or perineal surgery and indwelling catheter. Determine perineal-genital hygiene practices and self-care abilities.

Planning:

Delegation, perineal-genital care can be delegated to UAP. If the client has recently had perineal, rectal, or genital surgery, the nurse needs to assess if it is appropriate for the UAP to perform perineal-genital care. Prepare equipment to be used.

Equipment:

Perineal-genital care provided in conjunction with the bed bath: bath towel, bath blanket, clean gloves, bath basin with water at 43 to 46ºC (110 to 115ºF), soap and wash cloth.

Special perineal-genital care: bath towel, bath blanket, clean gloves, cotton balls or swabs, cotton balls or swabs, solution bottle, pitcher, or container filled with warm water or a prescribed solution, bedpan to receive rinse water, moisture-resistant bag or receptacle for use and perineal pad.

Implementation:

Determine whether the client is experiencing any discomfort in the perineal-genital area. Obtain and prepare the necessary equipment and supplies. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate, being particularly sensitive to any embarrassment felt by the client. Wash hands and observe other appropriate infection control procedures (e.g., clean gloves). Provide for client privacy by drawing the curtains around the bed or closing the door to the room. Some agencies provide signs indicating the need for privacy. Prepare the client: fold the top linen to the foot of the bed and fold the gown up to expose the genital area. Place a bath towel under the client’s hips. Position and drape the client and clean the upper inner thighs.

Position the male client in a supine position with knees slightly flexed and hips slightly externally rotated. Put on gloves, wash and dry the upper inner thighs. Inspect the perineal area. Note any particular areas of inflammation, excoriation, or swelling, especially between the labia in females and the scrotal folds in males. Also note excessive discharge or secretions from the orifices and the presence of odor. Wash and dry the penis, using firm strokes. If the client is uncircumcised, retract the prepuce (foreskin) to expose the glans penis (the tip of the penis) for cleaning. Replace the foreskin after cleaning the glans penis. Wash and dry the scrotum. The posterior folds of the scrotum may need to be cleaned when the buttocks are cleaned.          

Inspect the perineal orifices for intactness. Inspect particularly around the urethra in clients with indwelling catheters. Clean between the buttocks. Assist the client to turn onto the side facing away from you. Pay particular attention to the anal area and posterior folds of the scrotum in males. Clean the anus with toilet tissue before washing it, if necessary. Dry the area well. For postdelivery or menstruating females, apply a perineal pad as needed from front to back. Document any unusual findings such as redness, excoriation, skin breakdown, discharge or drainage and any localized areas of tenderness.

Evaluation:

Relate current assessment to previous assessments. Conduct appropriate follow-up such as prescribed ointment for excoriation. Report any deviation from normal to the physician.

Providing Perineal-Genital Care: Female

Assessment:

Assess for the presence of irritation, excoriation, inflammation or swelling, excessive discharge, odor, pain or discomfort, urinary or fecal incontinence, recent rectal or perineal surgery and indwelling catheter. Determine perineal-genital hygiene practices and self-care abilities.

Planning:

Delegation, perineal-genital care can be delegated to UAP. If the client has recently had perineal, rectal, or genital surgery, the nurse needs to assess if it is appropriate for the UAP to perform perineal-genital care. Prepare equipment to be used.

Equipment:

Perineal-genital care provided in conjunction with the bed bath: bath towel, bath blanket, clean gloves, bath basin with water at 43 to 46ºC (110 to 115ºF), soap and wash cloth.

Special perineal-genital care: bath towel, bath blanket, clean gloves, cotton balls or swabs, cotton balls or swabs, solution bottle, pitcher, or container filled with warm water or a prescribed solution, bedpan to receive rinse water, moisture-resistant bag or receptacle for use and perineal pad.

Implementation:

Determine whether the client is experiencing any discomfort in the perineal-genital area. Obtain and prepare the necessary equipment and supplies. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate, being particularly sensitive to any embarrassment felt by the client. Wash hands and observe other appropriate infection control procedures (e.g., clean gloves). Provide for client privacy by drawing the curtains around the bed or closing the door to the room. Some agencies provide signs indicating the need for privacy. Prepare the client: fold the top linen to the foot of the bed and fold the gown up to expose the genital area. Place a bath towel under the client’s hips. Position and drape the client and clean the upper inner thighs.

Position the female in back-lying position with the knees flexed and spread well apart. Cover her body and legs with the bath blanket. Drape the legs by tucking the bottom corners of the bath blanket under the inner sides of the legs. Bring the middle portion of the blanket up over the public area. Put on gloves, wash and dry the upper inner thighs. Inspect the perineal area. Note any particular areas of inflammation, excoriation, or swelling, especially between the labia in females and the scrotal folds in males. Also note excesswive discharge or secretions from the orifices and the presence of odor. Clean the labia majora. Then spread the labia to wash the folds between the labia majora and the labia minora. Use separate quarters of the washcloth for each stroke, and wipe  from the pubis to the rectum. For, menstruating women and clients with indwelling catheter, use clean wipes, cotton balls, or gauze. Take a clean ball for each stroke. Rinse the area well. You may place the client on a bedpan and use a periwash or solution bottle to pour warm water over the area. Dry the perineum thoroughly, paying particular attention to the folds between the labia.

Inspect the perineal orifices for intactness. Inspect particularly around the urethra in clients with indwelling catheters. Clean between the buttocks. Assist the client to turn onto the side facing away from you. Pay particular attention to the anal area and posterior folds of the scrotum in males. Clean the anus with toilet tissue before washing it, if necessary. Dry the area well. For postdelivery or menstruating females, apply a perineal pad as needed from front to back. Document any unusual findings such as redness, excoriation, skin breakdown, discharge or drainage and any localized areas of tenderness.

Evaluation:

Relate current assessment to previous assessments. Conduct appropriate follow-up such as prescribed ointment for excoriation. Report any deviation from normal to the physician.

Gowning and Gloving with Another Person

Planning/Implementation:

Gowning:

A team member in sterile gown and gloves may assist the surgeon by taking the following steps: Open the hand towel and lay it on the surgeon’s hand, being careful not to touch the hand. Unfold t.h0e gown carefully, holding it at the neckband. Keeping your hands on the outside of the Gown under a protective cuff of the neck and shoulder area, offer the inside of the gown to the surgeon. He or she slips the arms into the sleeves. Release the gown. The surgeon holds arms outstretched while he circulator pulls the gown onto the shoulder and adjusts the sleeves so that cuffs are properly placed. In doing so, only the inside of the gown is touched at the seams.

Gloving:

Pick up the right glove, grasp it firmly, with the fingers under the everted cuff. Hold the palm of the glove toward the surgeon. Stretch the cuff sufficiently for the surgeon to introduce the hand. Avoid touching the hand by holding your thumbs out. Exert upward pressure as the surgeon plunges the hand into the glove. Unfold the everted glove cuff over the cuff of the sleeve. Repeat for the left hand. If a sterile vest is needed, hold it for the surgeon to slip the hands into the armholes. Be careful not to contaminate gloved at the neck level. If the gown is a wraparound, assist the surgeon.

Occasionally a contaminated gown must be changed during a surgical procedure. The circular unfastens the neck and waist. Grasped at the shoulders, the gown is always removed first. The gloves are removed using glove-to-glove and then skin-to-skin technique. If only the sleeve is contaminated, a sterile sleeve maybe put on over the contaminated one.

The gown is always removed before the gloves at the end of the surgical procedure. The circular unfastens the neck and back closures of the gown so the wearer does not contaminate his or her scrub suit. If wearing a wraparound gown, the wearer unfastens the waist closure n front. The gown is always removed inside out to protect the arms and scrub suit from contaminated outside of the gown. To remove: Grasp the right shoulder of the loosened gown with the left hand and pull the gown downward from the shoulder and off the right arm, turning the sleeve inside out. Turn the outside of the gown away from the body with flexed elbows. Grasp left shoulder with the right hand and remove the gown entirely pulling it off inside out. Discard in a laundry hamper or in a trash receptacle (if disposable).

Benedict’s Test

Planning/Implementation:

Gather equipment needed, as follows: Test tube (10 cc), Urine, Benedict’s solution (5ml), Medicine dropper, Alcohol Lamp, Test tube holder and Test tube rack. Put 5 ml of benedict’s solution into the  test tube. Heat over flame. Drop 3-5 cc of urine and boil. Leave the mixture to cool at room temperature. Read and interpret the result. Record the result.

Interpretation Color Glucose Present

Blue                                         Negative

Green                                      Trace

Green with yellow precipitate     +

Yellow to dark green                   + +

Brown                                          + + +

Orange                                         + + + +

Explain to the client the significance of the findings and give health teachings.

Gowning and Gloving: Drying Hands and Arms

Planning/Implementation:

After scrubbing, hands and arms must be thoroughly dried before the sterile gown is donned to prevent contamination of the gown by strike through of organisms from wet skin. The gown package for the scrub person contains one sterile gown, folded before sterilization, with the inside out, so that the bare scrubbed hands will not contaminate the sterile outside of the gown. A towel for drying the hands is placed on top of the gown during packing. The hands is placed on top of the gown during packing the Hands are dried as follows. Reach down to the opened sterile package and pick up the towel. Be careful not to drip water onto the pack. Be sure no one is within arm’s reach. Open the towel full-length, holding one end away from non-sterile scrub attire. Bend slightly forward to avoid letting the towel touch the attire. Dry both hands thoroughly but independently. To dry one arm, hold the towel in the opposite hand and, using an oscillating motion of the arm, draw the towel up to the elbow. Carefully revere the towel, still holding it away from the body. Dry the opposite hand arm on the unused (now uppermost) end of the towel.