Week 1 - Drain Care, NG tube indications, insertion and removal Flashcards
Surgical wound drainage is used to what?
remove drainage from a wound bed to prevent infection and fluid that would delay wound healing
surgical wound drainage may be what?
- superficial to skin
- deep in organ
- deep in cavity or duct
open passive drainage systems use what?
soft flexible rubber tube to maintain opening in tissue
open passive drainage systems prevent what?
build up of fluid
close active system uses what?
vacuum system to withdraw fluid and collect in reservoir
what type of tube is placed in the surgical opening during the surgical procedure for a close active drainage system?
perforated silastic tube
What supplies is needed to complete a drain dressing?
- wound care kit
- sterile NS
- clean gloves
- hand sanitizer
- sterile gloves
- sterile safety pin
- sterile scissors
- specimen container
- alcohol swabs
- covering dressing
- tape
- suture scissors/ blade
- Y dressing
how long do you leave post op dressing intact for before changing it?
24-48hrs unless otherwise ordered
what is the steps for emptying a hemovac or JP?
- gradually reduce charge/ pressure of drain and face away
- empty contents into specimen container
- maintain sterility of port
- cleanse port with alcohol
- pre-charge/ close port
- secure device to gown with safety pin hanging below wound
- note characteristics
- document procedure
in regards to emptying a JP and hemovac what are some characteristics you need to note?
- amount
- color
- consistency
- odor
what is required for a removal of a JP or hemovac?
physicians order
what are the steps to remove a JP or hemovac?
- check for physician order
- empty drain and leave uncharged
- cleanse wound, drain site working from patient outward
- remove suture if in place
- stabilize skin over drain insertion site with gauze
- have pt take deep breath and slowly exhale
- smoothly remove drain with exhale in steady motion
- apply pressure over drain site for 2 minutes
- observe end of drain intact
- cleanse drain site when removing 4X4 gauze
- cover with sterile dressing
- assess site dressing 30 mins after removal for dressing dry/ intact or shadowing
- document procedure
What do you need to include in your documentation for a JP and hemovac removal?
- wound assessment
- characteristics of drainage on old dressing
- wound care provided
- characteristics of drainage from active drain
- type of dressing applied
What is the procedure for shortening a Penrose?
- shortening amount/ timeline will be ordered by physician
- done with routine sterile dressing change
- set up sterile field with added sterile scissors, safety pin and suture blade
- after cleansing of site, remove suture (first time)
- pull Penrose out of tissue as per shortening order
- insert sterile safety pin at new length and cut 2cm above new pin site
- apply Y dressing around tube site, secure covering dressing
- document procedure
what do you need to include in your documentation when shortening a Penrose?
- wound assessment
- characteristics of drainage on old dressing
- wound care provided
- shortening length of Penrose drain
- type of dressing applied
what is a nasogastric tube?
flexible plastic tube inserted through nostrils, down the nasopharynx, and into the stomach or upper portion of small instestine
what do weighted NG tubes have?
weight added to tip to assist with passage
what do some NG tubes have?
hydrophilic coating that needs to be soaked for 5-10 seconds to activate it
what are the sizes of NG tubes for paediatrics and for adults?
paediatrics
5-12 French
adults
12-18 french
what are levin tubes used for?
feeding
describe levin tubes
- smaller bore
- single lumen
- softer
- more flexible
- less irritating
salem-sump tubes for suction are what?
double lumen to vent to prevent suctioning to stomach and decrease tissue damage
what are the indications for a NG tube?
- gain access
- decompress
- treatment
- lavage
- prevent
- enteral feeding
- should not be performed in facial, head and neck or throat trauma
how do you prevent aspiration for an NG tube?
- do not lie pt flat
- put pt in semi fowlers
can people with an NG tube have oral intake?
no, unless ordered
what do you need to check prior to administering medication to a pt with an NG tube?
check position of NG tube
how long do you need to elevate the HOB after enteral feeding with an NG tube?
30-60 minutes
how do you prevent irritation with an NG tube?
- tape in place
- secure NG tube to pts gown
what are some complications of an NG tube?
- aspiration
- abdominal pain/ discomfort
- nausea
- patency compromised
- dehydration
what do you need to assess in regards to NG tubes?
- appropriate suction is set to prescribed pressure/ rate
- amount/ quality of gastric contents
- canister/ tubing securely connected/ free of kinks/ tension
- placement/ length changes
- oral health
- soar throat/ irritation
- lip/ mouth dryness
- abdominal distention
- bowel sounds
- Nausea/ vomiting
- flatus
- BM
what is involved in nursing care for an NG tube?
- irrigation of tube as ordered/ required
- positioning for comfort
- mouth care
- monitoring for skin breakdown/ nares
- pinned to gown/ tape secure
- no coiling of tubing in mouth
- assess pt’s ability to speak
what is another name for an NG tube?
salem pump
what do you need to assess prior to inserting an NG tube?
- nares
- any skin breakdown
- occlusions
- which nostril they breath out of the best
- SpO2 monitoring
- VS
prior to inserting an NG tube what do you need to do to the tube?
- conform and soften
- measure and mark
- lubricate
- prep pin
- prep tape
how do you prepare a patient for an NG tube insertion?
- place in high fowlers
- provide basin
- place blue pad on chest
- provide glass of water with straw
- ensure mucous membranes are moistened
how do you measure an NgG tube that ends in the stomach?
measure nose to ear then ear to xyphoid and add 15cm
How do you place a pt if they are unconscious and you need to insert an NG tube?
on right side
how do you measure an NG tube that ends in the duodenum?
measure nose to ear then ear to xyphoid and add 25cm
how do you insert an NG tube?
- get pt to tilt head down
- slowly into nostril along nasal floor toward ear
- advance tube slowly using a rotating motion until you feel push back
- get pt to tilt head up and assess for tube coiling
- ask pt to take small sips of water and swallow while they swallow advance tube 1 inch until measured length is inserted
- get pt to speak
- secure NG tube to nose and pin to gown
- apply suction or initiate feed
- document
what may a pt experience while inserting an NG tube?
- coughing
- gagging
- vomiting
what do you do if the patient gagging/ coughing while inserting NG tube? What could this indicate?
- stop
- may indicate tube is malpositioned in airway
- withdraw tube and reassess pt
- do not attempt reinsertion until pt respiratory pattern and O2 return to baseline
if patient has impaired swallowing/ cannot drink and you can’t offer them water while inserting an NG tube. What do you get them to do instead?
ask them to dry swallow instead
do you ever let go of the NG tube while inserting it?
no, you do not let go until tube is secured in place
how do you check NG placement?
- assessing stomach secretions can be clear, colourless, pale yellow or green
- assess pH of stomach secretions (pH 1-4)
what must be done prior to initiating medication or feeding through an NG tube?
X-ray to confirm placement
How do you remove an NG tube?
- check for order
- put pt in high fowlers
- provide basin/ tissue
- apply blue pad to chest
- remove tape/ unpin from gown
- flush with 50mL water or air
- get pt to tilt head down/ forward
- instruct pt to take deep breaths and hold
- remove in smooth fluid motion
- inspect tip
- provide oral/ nasal care
- document procedure
what do you need to include in your documentation for an NG tube?
- size, type and length of tube
- external length measured/ secured
- which nare was used
- confirmation of placement
- suction rate/ characteristic of output
- type/ rate of enteral feeding
- assessment performed
- pt’s tolerance
how often do you need to measure an NG tube?
- every shift and document
- visually monitor Q4Hr and before each use
