GASTRIC INTUBATION
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§ Chapter 31 study hints
§ NG tube: pliable tube inserted through the patient's nasopharynx into the
stomach
§ Allows removal of gastric contents and the introduction of solutions into
the stomach
§ Following major surgery
§ Conditions affecting GI tract altering normal peristalsis
§ Keeps stomach empty until normal peristalsis returns
, § Used occasionally for enteral feedings but a softer small-bore feeding
tube is preferred
Recognize the importance of monitoring a patient closely who has an IV. Identify
nursing assessments taken to monitor a patient with an IV.
Give this one a try later!
· Monitor every hour observing for signs of over hydration dehydration and
complications related to IV flow which include: infiltration, inflammation at
site, coolness to touch, tenderness around site, occluded VAD, kink or knot
in infusion tubing
Describe methods to maintain peristomal skin integrity
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· If peristomal skin is raw, blistered, or weeping, the skin surface will be
moist and the pouch will not adhere, making the patient vulnerable to more
severe skin breakdown. Consult the ostomy care nurse before proceeding
with placing a pouch over moist, damaged skin.
· The pouch should be changes every 3 to 7 days, not daily
· If the ostomy pouch is leaking, change it. Taping or pouching it to contain
effluent leaves the skin exposed to chemical or enzymatic irritation.
Leaking or perforated ostomy bags will cause skin deteration and infection.
Types of tubing for gastric intubation
Give this one a try later!
, § Levin Tube
- Single lumen
- Holes near the tip
- Tube connected to low intermittent suction
§ Salem Sump
- Preferred tube for stomach decompression
- Double lumen
o One for removal of gastric contents
o One to provide an air vent (prevents suctioning of gastric mucosa into
holes at the end of the tube)
o Blue "pigtail" is the air vent
- When the main lumen is connected to suction, the "pigtail" permits free,
continuous drainage of secretions
- Never!!!!!
o Clamp off the air vent
o Connect to suction
o Use for irrigation
o Suction is usually low intermittent...physician will order
Soap and Water
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- When hands are visibly dirty, soiled with blood or other body fluids15-20
seconds, scrubbing all surfaces
- Before eating
- After using the toilet
- When caring for patients with clostridium difficile (C.diff) or multidrug-
resistant organisms (MDROs): methicillin resistant Staphylococcus aureus -
MRSA, vancomycin- resistant enterococcus -VRE
Wound Exudates
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, · Serous: clear like plasma
· Sanguineous: bright red from fresh bleeding
· Serosanguineous: pink/blood tinged
· Purulent: thick and yellow, pale green or white
Describe how to obtain a mid-stream catch urine specimen
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· A patient begins to urinate and during the middle portion of the voiding
collects a specimen. The initial stream flushes the urethral orifice and
meatus of possible bacteria
· If female patient is menstruating, record this information on the lab slip
· Take specimen to lab within 15 minutes
· Refrigerate specimen if not taken to lab within 2 hours
Bundles
Give this one a try later!
group of interventions (for all patients receiving the targeted treatment)
that when implemented together result in better outcomes than when
implemented separately
Describing a Wound
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· Dehiscence: partial or total seperation of wound layers
· Eviseration: total separation of wound layers and protrusion of viscera
Give this one a try later!
§ Chapter 31 study hints
§ NG tube: pliable tube inserted through the patient's nasopharynx into the
stomach
§ Allows removal of gastric contents and the introduction of solutions into
the stomach
§ Following major surgery
§ Conditions affecting GI tract altering normal peristalsis
§ Keeps stomach empty until normal peristalsis returns
, § Used occasionally for enteral feedings but a softer small-bore feeding
tube is preferred
Recognize the importance of monitoring a patient closely who has an IV. Identify
nursing assessments taken to monitor a patient with an IV.
Give this one a try later!
· Monitor every hour observing for signs of over hydration dehydration and
complications related to IV flow which include: infiltration, inflammation at
site, coolness to touch, tenderness around site, occluded VAD, kink or knot
in infusion tubing
Describe methods to maintain peristomal skin integrity
Give this one a try later!
· If peristomal skin is raw, blistered, or weeping, the skin surface will be
moist and the pouch will not adhere, making the patient vulnerable to more
severe skin breakdown. Consult the ostomy care nurse before proceeding
with placing a pouch over moist, damaged skin.
· The pouch should be changes every 3 to 7 days, not daily
· If the ostomy pouch is leaking, change it. Taping or pouching it to contain
effluent leaves the skin exposed to chemical or enzymatic irritation.
Leaking or perforated ostomy bags will cause skin deteration and infection.
Types of tubing for gastric intubation
Give this one a try later!
, § Levin Tube
- Single lumen
- Holes near the tip
- Tube connected to low intermittent suction
§ Salem Sump
- Preferred tube for stomach decompression
- Double lumen
o One for removal of gastric contents
o One to provide an air vent (prevents suctioning of gastric mucosa into
holes at the end of the tube)
o Blue "pigtail" is the air vent
- When the main lumen is connected to suction, the "pigtail" permits free,
continuous drainage of secretions
- Never!!!!!
o Clamp off the air vent
o Connect to suction
o Use for irrigation
o Suction is usually low intermittent...physician will order
Soap and Water
Give this one a try later!
- When hands are visibly dirty, soiled with blood or other body fluids15-20
seconds, scrubbing all surfaces
- Before eating
- After using the toilet
- When caring for patients with clostridium difficile (C.diff) or multidrug-
resistant organisms (MDROs): methicillin resistant Staphylococcus aureus -
MRSA, vancomycin- resistant enterococcus -VRE
Wound Exudates
Give this one a try later!
, · Serous: clear like plasma
· Sanguineous: bright red from fresh bleeding
· Serosanguineous: pink/blood tinged
· Purulent: thick and yellow, pale green or white
Describe how to obtain a mid-stream catch urine specimen
Give this one a try later!
· A patient begins to urinate and during the middle portion of the voiding
collects a specimen. The initial stream flushes the urethral orifice and
meatus of possible bacteria
· If female patient is menstruating, record this information on the lab slip
· Take specimen to lab within 15 minutes
· Refrigerate specimen if not taken to lab within 2 hours
Bundles
Give this one a try later!
group of interventions (for all patients receiving the targeted treatment)
that when implemented together result in better outcomes than when
implemented separately
Describing a Wound
Give this one a try later!
· Dehiscence: partial or total seperation of wound layers
· Eviseration: total separation of wound layers and protrusion of viscera
