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NRSG 302 > Week 1 - Drain Care, NG tube indications, insertion and removal > Flashcards

Week 1 - Drain Care, NG tube indications, insertion and removal Flashcards

1
Q

Surgical wound drainage is used to what?

A

remove drainage from a wound bed to prevent infection and fluid that would delay wound healing

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2
Q

surgical wound drainage may be what?

A
  • superficial to skin
  • deep in organ
  • deep in cavity or duct
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3
Q

open passive drainage systems use what?

A

soft flexible rubber tube to maintain opening in tissue

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4
Q

open passive drainage systems prevent what?

A

build up of fluid

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5
Q

close active system uses what?

A

vacuum system to withdraw fluid and collect in reservoir

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6
Q

what type of tube is placed in the surgical opening during the surgical procedure for a close active drainage system?

A

perforated silastic tube

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7
Q

What supplies is needed to complete a drain dressing?

A
  • 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
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8
Q

how long do you leave post op dressing intact for before changing it?

A

24-48hrs unless otherwise ordered

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9
Q

what is the steps for emptying a hemovac or JP?

A
  • 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
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10
Q

in regards to emptying a JP and hemovac what are some characteristics you need to note?

A
  • amount
  • color
  • consistency
  • odor
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11
Q

what is required for a removal of a JP or hemovac?

A

physicians order

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12
Q

what are the steps to remove a JP or hemovac?

A
  • 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
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13
Q

What do you need to include in your documentation for a JP and hemovac removal?

A
  • wound assessment
  • characteristics of drainage on old dressing
  • wound care provided
  • characteristics of drainage from active drain
  • type of dressing applied
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14
Q

What is the procedure for shortening a Penrose?

A
  • 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
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15
Q

what do you need to include in your documentation when shortening a Penrose?

A
  • wound assessment
  • characteristics of drainage on old dressing
  • wound care provided
  • shortening length of Penrose drain
  • type of dressing applied
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16
Q

what is a nasogastric tube?

A

flexible plastic tube inserted through nostrils, down the nasopharynx, and into the stomach or upper portion of small instestine

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17
Q

what do weighted NG tubes have?

A

weight added to tip to assist with passage

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18
Q

what do some NG tubes have?

A

hydrophilic coating that needs to be soaked for 5-10 seconds to activate it

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19
Q

what are the sizes of NG tubes for paediatrics and for adults?

A

paediatrics
5-12 French

adults
12-18 french

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20
Q

what are levin tubes used for?

A

feeding

21
Q

describe levin tubes

A
  • smaller bore
  • single lumen
  • softer
  • more flexible
  • less irritating
22
Q

salem-sump tubes for suction are what?

A

double lumen to vent to prevent suctioning to stomach and decrease tissue damage

23
Q

what are the indications for a NG tube?

A
  • gain access
  • decompress
  • treatment
  • lavage
  • prevent
  • enteral feeding
  • should not be performed in facial, head and neck or throat trauma
24
Q

how do you prevent aspiration for an NG tube?

A
  • do not lie pt flat
  • put pt in semi fowlers
25
Q

can people with an NG tube have oral intake?

A

no, unless ordered

26
Q

what do you need to check prior to administering medication to a pt with an NG tube?

A

check position of NG tube

27
Q

how long do you need to elevate the HOB after enteral feeding with an NG tube?

A

30-60 minutes

28
Q

how do you prevent irritation with an NG tube?

A
  • tape in place
  • secure NG tube to pts gown
29
Q

what are some complications of an NG tube?

A
  • aspiration
  • abdominal pain/ discomfort
  • nausea
  • patency compromised
  • dehydration
30
Q

what do you need to assess in regards to NG tubes?

A
  • 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
31
Q

what is involved in nursing care for an NG tube?

A
  • 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
32
Q

what is another name for an NG tube?

A

salem pump

33
Q

what do you need to assess prior to inserting an NG tube?

A
  • nares
  • any skin breakdown
  • occlusions
  • which nostril they breath out of the best
  • SpO2 monitoring
  • VS
34
Q

prior to inserting an NG tube what do you need to do to the tube?

A
  • conform and soften
  • measure and mark
  • lubricate
  • prep pin
  • prep tape
35
Q

how do you prepare a patient for an NG tube insertion?

A
  • place in high fowlers
  • provide basin
  • place blue pad on chest
  • provide glass of water with straw
  • ensure mucous membranes are moistened
36
Q

how do you measure an NgG tube that ends in the stomach?

A

measure nose to ear then ear to xyphoid and add 15cm

37
Q

How do you place a pt if they are unconscious and you need to insert an NG tube?

A

on right side

38
Q

how do you measure an NG tube that ends in the duodenum?

A

measure nose to ear then ear to xyphoid and add 25cm

39
Q

how do you insert an NG tube?

A
  • 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
40
Q

what may a pt experience while inserting an NG tube?

A
  • coughing
  • gagging
  • vomiting
41
Q

what do you do if the patient gagging/ coughing while inserting NG tube? What could this indicate?

A
  • 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
42
Q

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?

A

ask them to dry swallow instead

43
Q

do you ever let go of the NG tube while inserting it?

A

no, you do not let go until tube is secured in place

44
Q

how do you check NG placement?

A
  • assessing stomach secretions can be clear, colourless, pale yellow or green
  • assess pH of stomach secretions (pH 1-4)
45
Q

what must be done prior to initiating medication or feeding through an NG tube?

A

X-ray to confirm placement

46
Q

How do you remove an NG tube?

A
  • 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
47
Q

what do you need to include in your documentation for an NG tube?

A
  • 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
48
Q

how often do you need to measure an NG tube?

A
  • every shift and document
  • visually monitor Q4Hr and before each use

NRSG 302 (8 decks)

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