NUR 222 Lecture Notes - Lecture 11: Lung Volumes, Nostril, Supine Position
21 May 2018
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NG Insertion/Care and Tube Feeding-(Enteral)
STERILE TECHNIQUE-Indwelling Foley and Specimens
Wound Care (pressure and surgical)
Drains, ace wraps, Negative Pressure or Wound Vac Therapy
Wound Staging and assessment
Wound terminology
Ostomy Care: Types, anatomy and assessment
Patient Teaching
Nasogastric Tube:
- Insertion Position: Fowler to High-Fowler position
- Use clean gloves, measure distance to insert the tube by placing the tube tip at the
patient’s nostril and extending it to the tip of the earlobe and then to the tip of xiphoid
process (mid-sternum)
- Non-sterile procedure but be as clean as possible → push downward because if not it’ll
get into the lungs/trachea; it may have gone into the lungs if the patient is severely
coughing, cyanotic, pulse ox. is low or they have pain in their chest
- Lubricate tip 2-4 inches with water-soluble lubricant
- Select appropriate nostril & gentle insert tube into nostril directing tube up & back along
floor of nose → when pharynx is reached, instruct patient to touch chin to chest
- While encouraging the patient to sip water/swallow, advance the tube until it reaches the
planned mark
- Stop when patient breathes, secure & measure exposed tube
- Oral care q 2-4 hours
- Must verify placement with x-ray → document results to confirm tube position as well as
size & type of NG tube, measurement from tip of nose to end of exposed tube
- Dale is the NG Securement Device that must be changed every 3 days
o Prep the skin before applying the holder, start with the nose pad and peel the
holder and apply to nose
Gastric Fluid: grassy green with particles, off-white, or clear & colorless
- Brown if old blood is present
pH: Gastric <5.5; intestinal > 7 and pleural > 6
Enteral Tube Feeding:
- Intermittent/Bolus: Delivered at regular intervals & use gravity or instillation or feeding
pump; bolus is given using a syringe in one large amount; patient cannot drink water
themselves so we have to deliver it to them q4 hr.; feeding may be continuous/
administered while patient sleeps→ promotes optimal absorption, risk for reflux and
aspiration, risk for bacterial growth (use smaller volumes)
- Continuous: Position the patient with HOB elevated 30-45 degrees; clean gloves, check
placement (attach syringe to end of tube to aspirate, check color & consistency of
aspirated contents, pH, and exposed tube length), measure gastric residual (amount of
feeding remaining in stomach) → aspirate all gastric contents with syringe (>200-250mL
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associated with high risk for aspiration), hold feeding if >200 mL on successive
assessment; if not, return the residual based on facility policy, flush tube with 30 mL of
water for irrigation; DON’T GIVE FULL DOSE AT ONE TIME, GIVE Pt. 35 mL & GO
UP IN INCREMENTS
- Clean gloves, prepare formula/feeding bag
o Check expiration date of formula, cleanse top of feeding container with
disinfectant before opening, pour formula into feeding bag and allow solution to
run thru tubing, close clamp, hang back on IV and adjust 12 inch above stomach,
label bag and tubing with date and time
- Administer formula → attach feeding setup to feeding tube, open clamp and regulate drip
per order, when feeding is almost done add 30-60 mL of water to feeding bag for
irrigation, clamp tubing before air enters, and disconnect feeding setup and cover with
cap
- When using syringe, regulate rate by adjusting the height of the syringe and have patient
remain upright for at least 1 hour after feeding
Evaluation: Measure residual volume, measure finger-stick glucose every 6 hours until max.
administration route is attained and tolerated for 24 hours, measure I & O and weight patient
daily, monitor labs: albumin, transferrin, pre-albumin, observe respiratory status and comfort
level, auscultate for bowel sounds and observe tube insertion site for skin breakdown
To remove: Put on gloves, unpin tube from patient’s gown, remove adhesive tape from
patient’s nose, clamp the tube with fingers by doubling tube on itself, instruct patient to take
a deep breath and hold it, quickly and carefully remove the tube while the patient holds
breath and offer mouth care/facial tissue to blow mouth
Complications of Feeding Tube:
1. Feeding Tube becomes clogged → to avoid this problem, flush the tube with 30 mL
water q4 hr. after checking the residual volume, don’t use cranberry juice to unclog
feeding tubes → use water
2. Pt. develops nausea/vomiting → ensure HOB is elevated, withhold tube feeding and
notify HCP, check patency of tube, aspirate for gastric residual and decrease
administration rate for cramping/nausea
3. Gastric residual exceeds 200 mL (check agency policy) → Notify health care provider to
determine if you need to hold feedings, maintain patient in semi-Fowler's position; have
head of bed elevated at least 30 degrees, reassess residual volume 1 hour after you stop
the feeding to determine if volume has lessened or increased. If it has increased, make
sure the health care provider is aware.
4. Patient develops diarrhea 3+ times in 24 hours; indicates possible intolerance → Notify
health care provider, report type of feeding, status of feeding tube, patient's tolerance, and
adverse effects. Confer with RD to determine need to modify type of formula,
concentration, or rate of infusion. Consider other causes (e.g., bacterial contamination of
the feeding, patient infection). Determine if patient is receiving antibiotics or medications
(e.g., those containing sorbitol) that will induce diarrhea. Provide skin care measure
Catheters: Need a doctor’s order
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- Introduction of catheter through urethra into bladder to withdraw urine from bladder
- Intermittent Urethral Catheters (Straight catheters)
o To drain the bladder for shorter periods (5-10mins)
o Has balloon port that inflates and the color is different (almost 100% of the time it
is red)
- Indwelling Urethral Catheters (Retention/Foley catheters)
o Used for continuous drainage
o Designed so it does not slip out of the bladder
o Check for allergies (read labels on packaging)
o “French” = size /gauge
▪ Example: 5,8,10,12 French for babies &14-16 French for adults
• Position Patient
• Female
• Dorsal recumbent position, if unable then Sims’ or lateral
• Ask them to bend knees if they’re able to
• Male
• Supine position with thighs slightly abducted (away from midline)
• Drape clients with sheet or bath blanket, exposing perineum or genitalia.
• Move trash can close to where you will be working
• Clean off working area (usually over bedside table)
• Open catheterization kit on clean over bedside table using sterile technique
• Apply sterile gloves
• Place underpad, plastic side down, under client, maintaining sterility
• Apply fenestrated sterile drape close to meatus as needed, maintaining sterility
• Organize supplies on sterile field
• Pour sterile antiseptic solution onto cotton balls, or open antiseptic swabsticks
• Generously lubricate the catheter
• Attach the prefilled syringe of saline to the port for the balloon
• Move sterile tray and contents on sterile drape close to the client
• With non-dominant hand, retract labia to fully expose urethral meatus,
• With dominant hand, use the antimicrobial to cleanse the perineal area, from front to
back, start with the far labial fold, the near labial fold, and directly over center of urethral
meatus,
• Pick up catheter, making sure to control the tip of the catheter without contaminating it
• Insert the catheter, advancing a total of (2 to 3 inches) or until urine flows out of
catheter’s end. When urine appears, advance catheter, another 2-3 inches. Do not use
force to insert a catheter.
• With non-dominant hand, secure catheter
• With dominant hand, and slowly inflate balloon, once full then remove syringe.
• Pull gently on catheter to feel resistance
• Secure tubing to patient’s leg (leave some slack) so if patient rolls over, they don’t
risk pulling out their catheter & can cause bloody urine or damage to urethra
• Secure drainage bag below bladder, to non-moving frame
1st: Clean the perineal area
• Put on clean gloves.
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