ATI Skills Module - Nasogastric Tube flashcards | Easy Notecards

ATI Skills Module - Nasogastric Tube flashcards | Easy Notecards ATI Skills Module - Nasogastric Tube 1. nasogastric tube insertion you'll need (equipment) stethoscope, penlight, and bath a towel. anesthetic agent, if allowed at your facility a cup of water, an empty cup for the aspirate, pH reagent strips, an emesis basin, a tongue blade, a permanent marker, and scissors. a tape or an attachment device to secure the tube in place, skin adhesive, and water- soluble gel to lubricate the first 4 inches of the nasogastric tube. a 60 mL or larger syringe to check tube placement and to flush the line. a tube fixation and anchoring device to secure tubing review patient's history for any possible contraindications for inserting the tube; problem w/ nosebleeds, nasal polyps, chronic sinus infections, or oral, facial, or sinus surgery; any history of aspiration; or anticoagulant therapy. Ensure privacy, and place your supplies near the client's bedside. Introduce yourself Perform hand hygiene Confirm identification of patient Make sure that a suction device and a suction catheter are available int he room for gastric decompression or lavage. Review the provider's orders for the type of tube and the needs for gastric lavage or decompression, Discuss the procedure with the client. Elevate the bed -> HIGH-FOWLER'S POSITION (reduces the risk of aspiration and promotes effecting swallowing) Make sure that the level of the bed is at the level of you hips perform hand hygiene prepare all equipment (on bed side table) open the tube's package, and prepare the lubricant don gloves use a penlight to assess each nasal passage. Look for any obstruction such as nasal polyps, irritation of the mucosa, or a septal defect. verify with patient if he/she have history like nosebleeds, nasal trauma, or nasal surgery. even if her record already states "no history" assess for a gag reflex by gently placing a tongue blade against your client's uvula. make an agreement with patient to make a hand gesture or sign if he/she feels any discomfort. measure the correct portion of 2. Gastric Decompression confirm that all your supplies are available at the patient's bedside identify yourself to the patient explain the plan to the patient provide privacy perform hand hygiene This study source was diodwennlotaidfeyd btyh1e00p0a00ti8e15n3t76421 from CourseH on :29:43 GMT -05:00 confirm the provider's orders for the type of suction and amount of suction pressure explain the procedure to the patient done gloves aspirate the stomach contents to check for the correct positioning of the tube examine the aspirate and measure the pH the probability of gastric placement is increased IF the aspirate has a grassy, green or brown appearance. OR is clear and colorless with mucus shreds and the pH is less than or equal to 5 place a towel or a disposable pad underneath the end of the nasogastric tube to prevent staining of the linen or the patient's clothing. check and make sure that the suction source is working properly, and that the dial is set to the correct type of suction and the prescribed amount of suction pressure. connect the nasogastric tube to the suction tubing remove gloves perform hand hygiene document the type and amount of suction as well as the drainage, including its amount, color, consistency, character, and odor. 3. Care and Maintenance of a nasogastric tube ensure privacy place equipment on the bedside introduce yourself perform hand hygiene confirm patient's identification done gloves assess the tube's placement by checking the marking on the tube directly below the naris, or by measuring the external tube length and comparing it with the length documented in the chart. aspirate the stomach contents to check for correct positioning of the tube examine the aspirate and measure the pH the probability of gastric placement is increased IF the aspirate has a grassy, green or brown appearance. OR is clear and colorless with mucus shreds and the pH is less than or equal to 5 measure the amount of irrigant int he syringe, and slowly instill the irrigant into the nasogastric tube reconnect the nasogastric tube to the suction source when using a sump tube, be sure to flush the vent's lumen with 10 to 20 mL of air to reestablish airflow. inspect the skin around the tube frequently for signs of irritation, redness, breakdown, or ulceration. clean the area around the tube at least every 8 hours. apply a water-based lubricant to the naris to keep the area moisturized provide frequent mouth care to keep the mucous membranes from becoming dry and irritated recommend lip balm for their lips if they appear dry perform hand hygiene document the type and amount of suction as well as the drainage, including its amount, color, consistency, character, and odor. 4. Removing a nasogastric tube ensure privacy place equipment on the bedside introduce yourself perform hand hygiene confirm patient's identification confirm the provider's orders for the type of suction and amount of suction pressure explain the procedure to the patient inform her that she might experience some nasal discomfort and gagging as you remove the tube. done gloves place a towel or a disposable pad over the patient's chest to protect her clothing and linen. Provider her with facial tissue. Assist the patient into a semi-Flowler's position to help prevent aspiration raise the bed up to your make sure that the tonsil-tip suction device is within reach, in case the patient needs oral suctioning after you remove the tube. Make sure that the level of the bed is at the level of you hips untape the tube from the patient's nose, and then detach the tube from the patient's gown. some tube have a distal balloon that has to be deflated prior to removal (follow manufacturer's instruction) Ask the patient to hold her breath to close off the epiglottis withdraw the tube gently and steady, wrapping it end over end in your hands to prevent splashing fluid onto you or the patient. once the distal end of the tube reaches the nasopharynx, remove it quickly inspect the tube to ensure that it is intact, and then discard the tube in the appropriate receptacle. father and dispose of all waste iin the appropriate receptacle. remove gloves perform hand hygiene Lower the head of the bed to a comfortable position for the patient perform hand hygiene document the procedure and the patient's response 5. When checking for nasogastric tube placement, the nurse should conduct which of the following procedure? a. Aspirate stomach contents and check the pH. b. Instill 20 mL of air into the tube and listen for a whooshing sound. c. Aspirate stomach contents and check their color. d. Auscultate lung sounds. Aspirate stomach contents and check the pH. Checking the pH of stomach contents is the recommended method for checking tube placement. 6. A nurse should recognize that nasogastric intubation is indicated to relieve gastric distention for which of the following patients? a. A 40-year-old patient with a postoperative bowel obstruction b. A 60-year-old patient admitted with gastrointestinal hemorrhage c. A 20-year-old patient with malabsorption syndrome This study source wdas. dAow6nl-oyadeead rby-o10ld000c0h81i5l3d76w42h1 ofrodmrCaonurkseHconsu07b-3s1t-2a0n21c1e6:29:43 GMT -05:00 A 40-year-old patient with a postoperative bowel obstruction A nasogastric tube should be placed for decompression for the removal of secretions. This will assist in relieving abdominal distention. 7. A nurse is caring for a patient who has a newly inserted nasogastric tube. Which of the following methods is appropriate for verifying the initial placement? a. pH measurement of gastric aspirate b. Color of gastric contents c. Auscultation of injected air d. X-ray examination of the chest and abdomen X-ray examination of the chest and abdomen X-ray examination is the gold standard for confirming the initial placement of a nasogastric tube. 8. A nurse is caring for a patient who has nasogastric tube connected to suction. Which of the following should indicate to the nurse that the tube has become occluded? a. Active bowel sounds b. Increase in gastric secretions c. Patient's report of nausea d. Passing flatus Patient's report of nausea Tubes connected to suction decompress the gastrointestinal tract. This is needed when peristalsis is absent. If gastric secretions are unable to move through the gastrointestinal tract and if the nasogastric tube is unable to evacuate the stomach due to an occlusion, nausea and vomiting will result. 9. During report, a nurse is informed that a patient has a nasogastric tube connected to continues suction. The nurse should recognize that this patient must have which of the following types of tube? a. Levin b. Ewald c. Sengstaken-Blakemore d. Salem sump A Salem sump A Salem sump is the only type of tube that allows for continuous suction. The tube has two lumens; one removes gastric contents and the other serves as an air vent. The vent allows air to enter the stomach, allowing the tube to float freely and preventing damage to the gastric mucosa. 10. A nurse is performing a nasogastric intubation. Which of the following actions should the nurse take immediately after inserting the tube to the predetermined length? a. Inspect the oropharynx with a penlight and a tongue blade. b. Aspirate gastric contents. c. Obtain an x-ray examination of the chest and abdomen. d. Tape the tube securely in place with a tube holder device Inspect the oropharynx with a penlight and a tongue blade. After insertion, the nurse should immediately inspect the oropharynx to check for kinks and to ensure that the tube is not coiled. 11. A patient recovering from gastric surgery remains NPO and has a nasogastric tube connected to suction. Which of the following actions should the nurse take to prevent dry mucous membranes? a. Provide frequent mouth care. b. Offer throat lozenges for the patient to use c. .Apply petroleum jelly to the patient's naris. d. Allow the patient to suck on ice chips. Provide frequent mouth care. Frequent mouth care (brushing teeth, oral swab) is a nursing intervention that prevents mucous membranes from becoming dry and irritated. 12. abdominal distention swelling in the area between the waist and the pelvis due to intestinal gas, overeating, or pathophysiological causes such as infection or hemorrhage 13. air vent a device or aperture that allows the entry or exit of air; on a nasogastric tube, a branch of the main tube that is always open to the air, providing continuous atmospheric air irrigation 14. antireflex valve a device that can also be inserted into a lumen of some types of nasogastric tubes to prevent the seepage of gastric contents out of the vented lumen 15. aspiration inadvertent inhalation of fluid or other substances into the lungs; also, the withdrawal or removal, via a syringe or other apparatus, of a substance or material from the body 16. decompression removal of stomach contents to relieve distention of the stomach and intestines caused by the accumulation of gastrointestinal air and fluid 17. epiglottis the lid-like cartilaginous structure overhanging the entrance to the larynx and preventing food from entering the larynx and the trachea during swallowing 18. esophagitis inflammation of the esophagus 19. esophagus the musculomembranous passage extending from the pharynx to the stomach 20. flatus gas or air generated in the stomach and/or intestines and expelled via the anus 21. gastric aspirate a substance or material obtained by withdrawal or removal, via a syringe and through a nasogastric, orogastric, or gastrostomy tube, from the patient’s stomach 22. ileus mechanical or functional obstruction of the intestines 23. irrigant a solution used for therapeutic irrigation or washing out of a body cavity or part 24. lavage therapeutic irrigation or washing out of a body cavity or part 25. lipid pneumonia lung inflammation that develops when fat particles enter the bronchial tree 26. lumen a cavity or bore of a tubular organ or part 27. menthemoglobinemia the presence of excessive methemoglobin (a non-oxygen-carrying pigment) in the blood 28. naris one of the two external orifices of the nose; nostril (plural: nares) 29. nasogastric tube a hollow, flexible, cylindrical device, inserted through the nose and extending to the stomach or intestines, that has multiple functions including serving as a conduit for removing gastrointestinal fluids and gas or delivering enteral feedings or medications 30. nasopharynx the portion of the pharynx (the passage between the mouth and posterior nares and the larynx and esophagus) lying above the level of the soft palate 31. paratid glands two salivary secretory organs located on either side of the face just below and in front of the ears 32. patency