MED- SURG FINAL EXAM STUDY GUIDE  Med Math

MED- SURG FINAL EXAM STUDY GUIDE  Med Math  NG tube – Placement and verification  Review the prescription & purpose of the procedure, understand the need for placement. Identify client, explain the procedure.  Review history of nasal problems, anticoagulants, previous trauma, & past history of aspiration.  Evaluate the clients ability to cooperate & make a hand signal w/ the client.  Perform hand hygiene, tape or use commercial fixation device to secure the dressing.  Use clean gloves, water soluble lube, topical anesthetic, cup of water & straw, catheter & syringe (30-60 mL), basin, pH strip (>4), clamp or plug to close the tubing after insertion.  Steps: ATI i. Auscultate bowel sounds, palpate abdomen for distention, pain & rigidity. ii. Raise head of bed (high fowlers if possible). iii. Assess nares, look for deviation/obstruction. iv. Measure tube from tip of the nose to the earlobe, down to the xiphoid process. v. Give client water & when they swallow continue to insert tubbing. 1. If client vomits clear the airway & provide comfort before continuing care. vi. Check for placement w/ pH strip (<4) & assess color, odor, consistency & amount. vii. Verify placement w/ X-RAY. 1. If the tube is not in the stomach, advance it 5 cm (2 in.) & repeat placement check. 2 MED- SURG FINAL EXAM STUDY GUIDE  Wound Evisceration – Nursing actions – what to do if you see evisceration?  Call for help, ask the surgeon to be notified & that needed supplies be brought to the room of the client.  Stay with the client.  While waiting for supplies, place the client in low fowlers w/ the knees bent.  Cover the wound with sterile wet normal saline dressing & keep the dressing moist. Do not attempt