Vn 15 Study 6 Flashcards
Homecare client education for PCA use
Don’t wait till pain is present
Nurse post-op assessment
Monitor for potential complications
Ensure patients air way
Helps maintain adequate circulation
Maintains proper position and function of drains tubes and IV infusion
Prevents or assist with treatment of shock
Client education included with discharge post op
Steps to Gastro Intubation
Gather and setup equipment: If large stiff tube place in warm water
•Inspect nasal: exclusions: nasal polyps; deviated septum; narrow passageway
•Measure using NEX: From NOSE to EARLOBE to the XIPHOID Process (tip of the sternum)
•Assess bowel sounds
•Raise head of the bed-hyperextend neck, decreases risk of aspiration
•High-fowler if feasible
•Lubricate and insert (tip backward and downward)
•Stop at first mark and inspect throat
Pre insertion assessment of GI tubes and the exclusions
•Level of Consciousness
•Weight
•Bowel Sounds
•Abdominal Distention
•Integrity of Nasal and Oral Mucosa
•Ability to swallow, cough, and gag
•Any Nausea and Vomiting
Exclusions
Diviated septum
Polups
Narrow passage ways
Signs of someone choking
Coughing or gaging while eating
Audibly wheezing
Persistently attempting to clear throat
Making hoarse or wet vocal sounds
Resisting efforts to be fed
Being unable to speak
Holding throat
Being unable to breathe
Excibiting cyanosis
Risk of fast feeding
Risk: dumping syndrome
•Aspiration: raise hob/fowlers
Intermittent Feedings-
The gradual instillation of liquid nourishment four to six times a day over 30 – 60 minutes. The usual volume is 250 – 400 mL.
Bolus Feedings
Rapid risk regurgitation
Acid reflux mimic normal of eating
the instillation of liquid nourishment in less than 30 minutes four to six times a day usually involves 250 mL – 400 mL of formula per administration.
Placement
Tube feeding administration sets are replaced every 24 hours regardless of the schedule.
What is an X-ray needed for ng tube
For permanent placement
Electric pimp
Gravity is not needed
