NURS 225 Lecture Notes - Lecture 4: Enterocolitis, Ileus, Serum Albumin
University of Pennsylvania School of Nursing
N 225 Pediatric Nursing
Helene Fuld Pavilion for Innovative Learning and Simulation
Fall 2016/ Student Guide
MODULE III: Nursing Care of the Patient with Nasogastric or Gastrointestinal Tube
Nursing Care of the Patient Receiving Enteral Feedings
As with any activity you must consult the policy and procedure manual of the healthcare
facility you are working at before commencing patient care to determine the specific
requirements of that setting.
Point values for each response to the objectives are in parenthesis
Total number of points: 50
Case 1: Ali is a 7 year old who presents to the Emergency Department for evaluation after a
motor-vehicle accident, she was restrained in the back of the car, however was wearing a lap-
belt, and not riding in a booster seat. She is alert and awake upon arrival, however has
significant bruising to her abdomen and paramedics report distention. The attending requests
that the bedside nurse places a nasogastric tube for Ali.
1. What is the purpose of placing a nasogastric tube for a patient with the above
presentation, and explain how this intervention would be effective in reducing
gastric distention? (Perry & Potter) 2 points
The purpose of inserting a nasogastric tube for this patient is for gastric decompression.
This nasogastric tube keeps the stomach empty until normal peristalsis returns
2. What type of Nasogastric tube will the nurse anticipate using for gastric
decompression? (Perry & Potter) 1 point
A Salem sump tube
3. Indicate how to appropriately measure the length of insertion for the Nasogastric
tube. How can you mark your distance for insertion? (Perry and Potter) 2 points
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Measure distance from tip of nose, to earlobe and to the xiphoid process. You can mark
the length that will be inserted with a small piece of tape around the tube.
4. Ali is very tearful prior to the insertion of the nasogastric tube. What strategy can
assist in passing the nasogastric tube? (Perry and Potter) 1 point
Before the procedure begins, the nurse should develop hand signals with the patient in the case
that the patient cannot handle the procedure. The nurse should lubricate 7.5-10 cm of the tube
and alert the patient when the procedure will begin. If the nurse hits resistance during insertion,
she should apply downward pressure and try to rotate tube if needed.
5. Which port of the nasogastric tube will be attached to suction? (Perry & Potter) 1
point
The port of the main lumen is used for suctioning
6. What are two other pediatric etiologies that would require a nasogastric tube for
decompression? (Ball, Binder, and Cowen, Ch. 25) 1 point
Intussusception, small bowel obstruction
7. On a salem sump, there is a second “blue” port. What is the purpose of this other
port? (Perry & Potter) 1 point
This is the air vent that connects with the second lumen. When the main lumen is connected to
suction, the air vent permits free, continuous drainage of secretions
8. During insertion of the nasogastric tube the nurse should monitor for what signs of
distress? What would these symptoms indicate? (Perry & Potter) 4 points
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During insertion, the nurse should monitor for coughing, fever, shortness of breath or
pulmonary congestion. This may indicate the tube is obstructing the airway because it
entered the trachea.
9. What is the correct action by the nurse should they observe these signs of distress?
(Perry & Potter) 2 point
Perform complete respiratory assessment, notify HCP, and obtain chest x-ray film
examination as ordered.
10. After inserting the nasogastric tube to the desired length, the nurse appropriately
secures the tube to Ali’s skin. What are two methods to confirm placement of the
nasogastric tube? (Perry and Potter) 4 points
Attach Asepto or catheter-tipped syringe to end of tube. Aspirate gently back on syringe to
obtain gastric contents. Observe color and use Gastroccult pH paper to measure aspirate for pH.
Another method is to contact HCP to order a chest and abdomen x-ray.
11. The nurse just inserted the nasogastric tube in Ali’s right nare; she is unable to
aspirate any gastric content, however, Ali is exhibiting no signs of distress. She
attaches the clear lumen to the suction at low continuous suction. Is this the correct
action? Why or why not? 3 points
This was not the correct action. Nasogastric tube placement must be confirmed before it can be
attached to suction. Without confirming placement, the suction may be ineffective in providing
decompression or it could be dangerous to the patient.
Case 2: Jimmy is a 2 year old with a past medical history of premature birth at 32 weeks
gestation, and necrotizing enterocolitis. Jimmy’s necrotizing enterocolitis infection was
identified rather early, and he needed to have some bowel removed. At this time he is not on
enteral supplementation for growth and development. He was brought into the emergency
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Document Summary
Helene fuld pavilion for innovative learning and simulation. Nursing care of the patient receiving enteral feedings. Module iii: nursing care of the patient with nasogastric or gastrointestinal tube. As with any activity you must consult the policy and procedure manual of the healthcare facility you are working at before commencing patient care to determine the specific requirements of that setting. Point values for each response to the objectives are in parenthesis. She is alert and awake upon arrival, however has significant bruising to her abdomen and paramedics report distention. The purpose of inserting a nasogastric tube for this patient is for gastric decompression. This nasogastric tube keeps the stomach empty until normal peristalsis returns: what type of nasogastric tube will the nurse anticipate using for gastric decompression? (perry & potter) 1 point. A salem sump tube: indicate how to appropriately measure the length of insertion for the nasogastric tube.
