Fundamental & Advanced Nursing Skills_2 pptx

Skill 6-7 Applying a Condom Catheter Skill 6-8 Inserting an Indwelling Catheter: Male Skill 6-9 Inserting an Indwelling Catheter: Female Skill 6-10 Routine Catheter Care Skill 6-11 Obtaining a Residual Urine Specimen from an Indwelling Catheter Skill 6-12 Irrigating a Urinary Catheter Skill 6-13 Irrigating the Bladder Using a Closed-System Catheter Skill 6-14 Removing an Indwelling Catheter Skill 6-15 Catheterizing a Noncontinent Urinary Diversion Skill 6-16 Maintaining a Continent Urinary Diversion Skill 6-17 Pouching a Noncontinent Urinary Diversion Skill 6-18 Administering Peritoneal Dialysis Skill 6-19 Administering an Enema Skill 6-20 Digital Removal of Fecal Impaction Skill 6-21 Inserting a Rectal Tube Skill 6-22 Irrigating and Cleaning a Stoma Skill 6-23 Changing a Bowel Diversion Ostomy Appliance: Pouching a Stoma Skill 6-1 Inserting and Maintaining a Nasogastric Tube Skill 6-2 Assessing Placement of a Large-Bore Feeding Tube Skill 6-3 Assessing Placement of a Small-Bore Feeding Tube Skill 6-4 Removing a Nasogastric Tube Skill 6-5 Feeding and Medicating Via a Gastrostomy Tube Skill 6-6 Maintaining Gastrointestinal Suction Devices Nutrition and Elimination CHAPTER 6 6 645 646 > ASSESSMENT 1. Assess client’s consciousness level to determine the ability of the client to cooperate during the procedure. 2. Check the client’s chart for any previous medical history of nostril surgery or injury or unusual nos- tril bleeding. Reduces risk of injury from the tube. 3. Use a penlight to assess nostrils for a deviated sep- tum. Facilitates choice of nostril and size of tube. 4. Ask the client to breathe through each nostril oc- cluding the other with a finger. Facilitates choice of nostril and decreases chance that tube will in- terfere with respirations. > DIAGNOSIS 1.1.2.2 Altered Nutrition: Less Than Body Requirement 6.5.1.1 Swallowing Impairment 1.6.1.4 Risk for Aspiration 1.3.1.2 Risk for Diarrhea 1.6.2.1.1 Altered Oral Mucous Membranes 1.4.1.2.2.1 Risk for Fluid Volume Deficit 9.1.1 Pain 1.6.2.1.2.1 Impaired Skin Integrity > PLANNING Expected Outcomes: 1. Client’s nutritional status will improve, as indi- cated by increased body weight, physical strength, and mental status. 2. Client’s nutritional needs will be met with the as- sistance of tube feeding. Inserting and Maintaining a Nasogastric Tube Hsin-Yi Tang, RN, MS, and Jung-Chen Chang, RN, MN SKILL 6-1 SKILL 6-1 Decompression Double lumen Gastric content Gastrointestinal surgery Levin’s tube Nasogastric tube Peptic ulcer Salem sump tube Single lumen Tube feeding KEY TERMS > OVERVIEW OF THE SKILL Nasogastric (NG) tubes are used for several purposes, including feeding for nutrition when the client is co- matose, semiconscious, or unable to consume sufficient nutrition orally. Nasogastric suction tubes are used for decompression of gastric content after gastrointestinal surgery, and to obtain gastric specimens for diagnosis of peptic ulcer. Tubes are used for irrigation to clean and flush the stomach after oral ingestion of poisonous sub- stances. Finally, NG tubes are used to document the presence of blood in the stomach, monitor the amount of bleeding from the stomach, and identify the recur- rence of bleeding in the stomach. The two most commonly used NG tubes are the single lumen Levin’s tube, and the double lumen Salem sump tube. The gastrointestinal tract is considered to be a clean area rather than a sterile one. The procedure to place an NG tube is performed using clean technique unless it is performed in conjunction with gastroin- testinal surgery. 3. Client will maintain a patent airway, as evidenced by absence of coughing, no shortness of breath, and no aspiration. 4. Client will not have diarrhea due to nasogastric feeding. 5. Mouth mucous membranes will remain moist and intact. 6. Client will maintain a normal fluid volume, as evi- denced by good skin texture, muscle tone, and blood volume. 7. Client’s comfort level will increase. 8. Skin around the tube will remain intact, with no redness or blisters. Equipment Needed: • Nasogastric tube: adult, 14 to 18 French; child/ infant, 5 to 10 French; single lumen (Levin’s sump): feeding; double lumen (Salem sump tube): feeding, suction, irrigation (see Figure 6-1-2) • Water-soluble lubricant • Syringe with catheter tip or adapter, 20-50 ml • Glass of tap water with straw, or ice • Towel or tissue • Emesis basin with ice chips • Tongue blade • pH chemstrip • Stethoscope • Disposable gloves (nonsterile), goggles, gown • Hypoallergenic tape, rubber band, and safety pin • Penlight or flashlight • Disposable irrigation set (if needed) • Wall mount or portable suction equipment (if needed) • Administration set with pump or controller for feeding tube > CLIENT EDUCATION NEEDED: 1. Inform the client of the purpose of the NG tube. 2. Explain the procedure of insertion and any ex- pected discomfort. 3. Establish and clarify a “hand signal” to indicate the need to temporarily stop the NG insertion. 4. Explain how the client can cooperate during tube insertion, especially by swallowing water when asked to do so. 5. Explain potential complications, such as diarrhea, mouth dryness, and nostril irritation. 6. Review the skills and procedures of maintaining tube. 7. Instruct to chew on ice chips to satisfy the basic need to eat (if there is no fluid intake restriction). 8. Encourage physical activity to enhance gastroin- testinal mobility (if there is no activity restriction). 9. If a client with dentures is conscious, encourage to wear the dentures to maintain the normal shape of oral cavity. SKILL 6-1 Inserting and Maintaining a Nasogastric Tube 647 Estimated time to complete the skill: 15–20 minutes Figure 6-1-2 Double-lumen nasogastric tube IMPLEMENTATION—ACTION/RATIONALE ACTION RATIONALE 1. To assess for any nostril surgery and abnormal bleeding. 2. Decreases anxiety and promotes cooperation. 1. Review client’s medical history. 2. Assess client’s consciousness and ability to un- derstand. Explain the procedure and develop a hand signal (see Figure 6-1-3). continues 648 CHAPTER 6 Nutrition and Elimination 3. Facilitates an efficient procedure. 4. Facilitates insertion and prevents back strain. 5. Practices clean technique. 6. Choosing the more patent nostril for insertion decreases discomfort and unnecessary trauma. 3. Prepare the equipment, putting tissues, a cup of water, and an emesis basin nearby (see Fig- ure 6-1-4). 4. Prepare the environment; raise the bed and place it in a high Fowler’s position (45 to 60 degrees). Cover the chest with a towel. 5. Wash hands and then put on gloves. 6. Use a penlight to view the client’s nostrils. As- sess client’s nostrils with penlight and have the client blow her nose one nostril at a time (see Figure 6-1-5). 7. Using the NG tube, measure the distance from the bridge of the nose to the earlobe and then to the xiphoid process of the sternum and mark this distance on the tube with a piece of tape (see Figure 6-1-6). 8. Lubricate first 4 inches of the tube with water- soluble lubricant. 9. Ask the client to slightly flex the neck backward. 7. Determines the approximate amount of tube needed to reach the stomach. 8. Facilitates passage into the naris. 9. Makes insertion easier. Figure 6-1-4 Put an emesis basin, cup with straw, and tissues nearby. Figure 6-1-3 Explain the procedure; demonstrate head position and tube insertion. Figure 6-1-5 Assess the client’s nostrils before intro- ducing the nasogastric tube. Figure 6-1-6 Measure the distance from nose to ear- lobe to the xiphoid process to determine how much tube will need to be inserted to reach the stomach. SKILL 6-1 Inserting and Maintaining a Nasogastric Tube 649 10. Promotes passage of tube with minimal trauma to mucosa. 10. Gently insert the tube into a naris (see Fig- ure 6-1-7) 11. Ask the client to tip the head forward once the tube reaches the nasopharynx. If the client continues to gag, stop a moment. 12. Advance the tube several inches at a time as the client swallows water or ice chips (see Fig- ure 6-1-8). 13. Withdraw the tube immediately if there are signs of respiratory distress. 14. Advance the tube until the taped mark is reached (see Figure 6-1-9). 15. Split a 4-inch strip of tape lengthwise 2 inches. Secure the tube with the tape by placing the wide portion of the tape on the bridge of the nose and wrapping the split ends around the tube (see Figure 6-1-10).Tape to cheek as well if desired (see Figure 6-1-11). 15. Prevents tube displacement. 11. Tipping the head forward facilitates passage of the tube into the esophagus instead of the tra- chea.Tube may stimulate gag reflex. Allows the client to rest, reduces anxiety,and prevents vomiting. 12. Assists in pushing the tube past the oropharynx. 13. Prevents trauma to bronchus or lung. 14. Enables the tube to reach the stomach. continues Figure 6-1-7 Gently insert the tube into the naris. Figure 6-1-8 Advance the tube slowly.The client swal- lows small sips of water to assist in pushing the tube past the oropharnyx. Figure 6-1-9 Advance the tube until the taped mark is at the opening of the naris. Figure 6-1-10 Secure the tube to the nose. 650 CHAPTER 6 Nutrition and Elimination 16. Ensures correct placement. (A pH below 4 indi- cates the tube is in the stomach; a pH range of 6–7 indicates intestinal sites.) 16. Check the placement of the tube: • Attach the syringe to the end of the tube for injecting 10 cc of air and auscultate over the epigastric area (upper left quadrant); see Figure 6-1-12. • Aspirate sample gastric content and mea- sure with chemstrip pH (see Figure 6-1-13). • Prepare the client for x-ray check-up, if prescribed. 17. Connect the distal end of the tube to suction, draining bag, or adapter (see Figure 6-1-14). 18. Secure the tube with rubber band and safety pin to client’s gown or bed sheet. 19. Remove gloves, dispose of contaminated ma- terials in proper container, and wash hands. 20. Position client comfortably and place the call light in easy reach. 21. Document procedure. 17. Establishes an appropriate pathway for intervention. 18. Enhances the level of comfort and secures the tubing system. 19. Implements the principles of infection control. 20. Decreases client’s anxiety and provides access to help if needed. 21. Records implementation of intervention and promotes continuity of care. Figure 6-1-11 Tape the tube to the cheek as well, if de- sired, to provide extra support. Figure 6-1-12 Auscultate over the epigastric area. Figure 6-1-13 Aspirate a sample of gastric content to check for pH. Figure 6-1-14 Connect the distal end of the tube to suction or drainage to complete the procedure. SKILL 6-1 Inserting and Maintaining a Nasogastric Tube 651 22. Reduces the transmission of microorganisms. 23. Prevents complications from dislocation of the tube. 24. Prevents complications from the loss of benefi- cial effects from the tube. 25. Rotation or irrigation may disturb incisions. 26. Enhances client’s comfort and the integrity of skin and nose mucosa. 27. Reduces the transmission of microorganisms. Maintaining a Nasogastric Tube 22. Wash hands and apply gloves. 23. Follow the steps in Action 16 to check the proper tubing position before instilling any- thing per NG tube or at least every 8 hours. 24. Assess for signs that the tube has become blocked, including epigastric pain and vomit- ing, and/or the inability to pass medications or feedings through the tube. 25. Remember never to irrigate or rotate a tube that has been placed by the physician or quali- fied practitioner during gastric or esophageal surgery. 26. Provide oral hygiene and assist client to clean nares daily. 27. Remove gloves, dispose of contaminated ma- terials in proper container, and wash hands. ▼ REAL WORLD ANECDOTES Mr. Klotz had just been admitted to the hospital with severe abdominal distention. NG tube placement was ordered for abdominal decompression. Mr. Klotz was not to have any fluids by mouth but he could have ice chips. The nurse provided Mr. Klotz with ice chips and instructed him to suck on a few chips and swallow as she inserted the NG tube. The nurse inserted the NG tube into Mr. Klotz’s right naris but was unable to advance the tube any further than an inch. After several > EVALUATION • Client’s nutritional status improves, as indicated by increased body weight, physical strength, and men- tal status. • Client’s nutritional needs are met with the assis- tance of tube feeding. • Client maintains a patent airway, as evidenced by absence of coughing, no shortness of breath, and no aspiration. • Client does not have diarrhea due to nasogastric feeding. • Mouth mucous membranes remain moist and intact. • Client maintains a normal fluid volume, as evi- denced by good skin texture, muscle tone, and blood volume. • Client’s comfort level increases. • Skin around the tube remains intact, with no red- ness or blisters. > DOCUMENTATION Nurses’ Notes • Document the type of NG tube inserted, the naris used, how the client tolerated the procedure, and the methods used to verify placement. • Document care provided to the client to increase comfort of the NG insertion naris. • Note any unusual findings. Intake and Output Record • Note the amount of fluid the client drank to aid in- sertion of the NG tube. • Note the amount of gastric contents removed for testing. continues > CRITICAL THINKING SKILL Introduction Nurses must be able to evaluate the effectiveness of NG tube insertion, maintenance, or removal. Possible Scenario The family of your home care client has been assisting in her care, including the care of her feeding tube. You have educated them on the tube and its placement. Al- though they state they secured the tube in a proper place and the end of the tube is currently positioned higher than the stomach, you observe the tube is filled with gastric content. Possible Outcome Client has a continuous risk for infection, electrolyte imbalance, and potential aspiration. Prevention Assess that the caregiver is properly securing the end of the tube at a level higher than the stomach. Assess the client’s vital signs and respiratory pattern for infection, electrolyte imbalance, or aspiration. Reeducate the care- givers on assessing for correct tube placement, and re- view with them common situations where the tube might move. 652 CHAPTER 6 Nutrition and Elimination ▼ REAL WORLD ANECDOTES continued attempts to advance the tube, the nurse tried Mr. Klotz’s left naris. It required several gentle attempts and lots of lubricant to pass the tube into the nasopharynx, the nurse was finally able to advance the tube into Mr. Klotz’s stomach. After Mr. Klotz had received some relief from his distention, he did mention to the nurse that he had broken his nose many years earlier. ▼ VARIATIONS Geriatric Variations: • For elderly clients who wear dentures, oral hygiene and denture care should not be overlooked simply because an NG tube is in place. Pediatric Variations: • Dispose of, or securely tape any small parts, such as plastic connectors or plugs, to prevent small children from accidentally aspirating or swallowing them. Home Care Variations: • Periodically assess the family member’s ability to check the placement of the tube, check residual gastric contents, administer tube feedings, or connect the tube properly with suction. Long-Term Care Variations: • Teach family members or caregivers to assess client’s nutritional status and assess for any sign of complications related to the NG tube. ▼COMMON ERRORS—ASK YOURSELF Possible Error: The nurse is unable to auscultate air bubbles but assumes the NG tube is in place anyway. Ask Yourself: How do I prevent this error? > NURSING TIPS • Adjust the height of the bed to eliminate back strain. • Prepare the split tape before putting on gloves. • This can be an anxiety-provoking procedure. Good communication skills decrease anxiety and promote the client’s cooperation. • The size of the NG tube used depends on client size, client history of damage to the structure of the nose, and the purpose of the procedure. • Tincture of Benzoine may be used to prep the skin. This acts as an adhesive as well as a skin prep. • Carefully observe client’s verbal and nonverbal re- sponses during the entire procedure. • When feasible, engage family members or caregivers to assist in NG tube insertion. • Sump tubes should whistle continuously on low suction. SKILL 6-1 Inserting and Maintaining a Nasogastric Tube 653 ▼COMMON ERRORS—ASK YOURSELF continued Prevention: If you are unable to verify NG tube position by auscultating air, use another method of verification. Attempt to aspirate gastric contents. Place the end of the NG tube in a glass of water and check for air bubbles that correspond to the client’s exhalations. If you are unable to verify NG tube placement, do not instill anything through the tube. Notify the client’s qualified practitioner. Send the client for an x-ray to verify placement if this is within institutional guidelines. 654 > ASSESSMENT 1. Check the physician’s or qualified practitioner’s order for the type and size of feeding tube to en- sure accurate placement of the correct tube. 2. Review the client’s medical record for a history of prior tube use or displacement since recurring tube displacement may increase the risk of pul- monary placement. 3. Assess the client for signs and symptoms of inad- vertent respiratory placement since coughing, choking, and cyanosis may indicate placement of the tube in an airway. 4. Assess the client for signs and symptoms that in- crease the client’s risk of tube dislocation. Cough- ing, retching, and nasotracheal suctioning may cause the tube to become dislodged. Assessing Placement of a Large-Bore Feeding Tube Kathy Lilleby, RN SKILL 6-2 SKILL 6-2 Aspiration Large-bore feeding tube Nasoduodenal tube Nasogastric tube PEG PEJ pH KEY TERMS > OVERVIEW OF THE SKILL Clients who cannot take food or fluids orally may require the placement of a feeding tube for enteral nutrition. These clients may be unconscious, unable to respond to the thirst reflex, unable to swallow, or receiving a hyperosmotic enteral preparation. The large-bore nasogastric feeding tube requires a physician’s or qualified practitioner’s order to be placed. The tube can be a firm, polyvinyl large-bore tube or a soft, flexible polyurethane or silicone tube. After insertion, the placement should be checked by x-ray to determine that it is in the stomach or in the intestine as ordered and not in an airway. After the initial x-ray for placement, it is the nurse’s responsibility to verify the tube’s position before each intermittent feeding or medication or once a shift if the client is receiving continuous feedings. There are several types of large-bore feeding tubes. A nasogastric tube is for short-term use; the major complication of its use is aspiration pneumonia. The nasoduodenal tube is also used short term. There is less risk of aspiration with this tube, since the tip is weighted and rests in the duodenum. But it is also more difficult to place, and some institutions require that a physician or qualified practitioner insert this type of tube. The gastrostomy tube (GT) is placed surgically by laparoscopy for long-term use. The more common percutaneous endoscopic gastrostomy (PEG) tube is placed at the bedside under local anesthesia and con- scious sedation. A PEG tube is used for long-term feed- ings. The percutaneous endoscopic jejunostomy (PEJ) tube may also be placed at the bedside by the physician or qualified practitioner. It is more comfortable for the client and carries minimal risk of aspiration. [...]... respiratory complications These complications may not appear until after the tube is removed SKILL 6-5 Feeding and Medicating via a Gastrostomy Tube Karrin Johnson, RN (Adapted from Fundamentals of Nursing: Standards & Practice, by Sue C DeLaune and Patricia K Ladner, 1998, Albany, NY: Delmar Publishers.) KEY TERMS Aspiration Distention Gastrostomy Jejunum Lumen Patent Percutaneous endoscopic gastrostomy... to hear air rush, always reassess, or ask a coworker to assist Use one hand for syringe and one hand to hold diaphragm of stethoscope SKILL 6-3 Assessing Placement of a Small-Bore Feeding Tube 665 > NURSING TIPS • Elevate the bed to a good height for you • A 60-ml syringe works best if you expect a lot of aspirate • Involve the client; ask them to hold the tubing if you need help • Remove tube and... ASSESSMENT 1 Assess client’s consciousness level to determine the ability of the client to cooperate during the NG tube removal 2 Check the client’s chart for orders to remove the tube Reduces the risk for a nursing error and the need to reinsert the tube 666 If any problems are noted, report these findings and verify the order to remove the tube before proceeding After the removal, the nurse should monitor... continued Ask Yourself: How do I prevent this error? Prevention: Assess the client for signs of choking or coughing Notify the physician or qualified practitioner immediately if aspiration is suspected > NURSING TIPS • Adjust the height of bed to eliminate back strain when removing the tube • This can be an anxiety-provoking procedure Remind the client that tube removal is quick and painless compared to... will be obtained Write this plan into the client’s plan of care so all staff can comply If this error does occur, flush the tube with 30 ml warm water Wait 1 hour Begin tube placement assessment again > NURSING TIPS • A muffled or faint sound of injected air may signal that the tube is in the lungs • It may be necessary to inject air two or three times in obese clients since the sound of injected air may... between feedings 34 Ensures adequate hydration 35 Remove gloves and wash hands 35 Reduces transmission of microorganisms 36 Record total amount of formula and water administered on intake and output (I&O) form and client’s response to feeding 36 Documents administration of feeding and achievement of expected outcome; e.g., client tolerates feeding and weight is maintained or increased 678 CHAPTER 6... date, formula, and amount of feeding • Record the amount of tube feeding instilled and the amount of water used to flush the feeding tube w REAL WORLD ANECDOTES Penny was a long-term care client in a nursing facility She was an elderly frail woman with a long-term gastrostomy tube She had shared this room with the same roommate for several years Shortly after her roommate died, Penny began to be confused... breeding ground for bacteria The tube is also much more likely to become occluded by formula and medication particles, leaving the nurse with the problem of unplugging the feeding tube for the next feeding > NURSING TIPS • If a feeding tube becomes plugged or seems to be running slowly, water, a carbonated beverage, or cranberry juice instilled into the tube will sometimes help clean out the inside of the . aspiration. > DIAGNOSIS 1.1 .2. 1 Altered Nutrition: More Than Body Requirements 1.1 .2. 2 Altered Nutrition: Less Than Body Requirements 1.4.1 .2. 2 .2 Risk. Diarrhea 1.6 .2. 1.1 Altered Oral Mucous Membranes 1.4.1 .2. 2.1 Risk for Fluid Volume Deficit 9.1.1 Pain 1.6 .2. 1 .2. 1 Impaired Skin Integrity > PLANNING Expected