Week 1- NG and penrose drain Flashcards
A nasogastric (NG) tube is a ________inserted from _____ into _________
flexible
nostril
stomach or upper part of the SI
pediatric and adult size of NG
5-12 fr
12-18 Fr
some tubes may have a _______coating
hydrophilic coating that needs to be soaked for 5-10 sec to activate it
Indications for NG tube (5)
Gain access to GI tract
Decompress stomach (air, toxins, GI contents)
Lavage (wash if there has been a poisoning or oral drug overdose)
Enteral feeding
Instilling medications
contraindications of NG tubes
(2)
Should not be performed in facial, head and neck or throat trauma
Should have a gag reflex (or airway needs to be protected with an artificial airway) gagging closes the epiglottis
might be put on suction when have
a small bowel obstruction
large bore NG tube
hard bore
Salem sump
Larger tube
double lumen (main tube/smaller air vent lumen)
With holes near the tip
large bore may also be used for
suction as the smaller vent lumen allows for an inflow of air which prevents a vacuum if the tube adheres to the stomach wall.
Decreases tissue damage (blue pigtail section
soft bore NG
- characteristics of tube
- often used with
- most commonly used for
- FR size
- may have a ___ tip
- how often changed
- more often used to put
Levin
Single lumen, softer, more flexible
Often used with anti-reflux valve
Most common for enteral feeding in IH
Usually 6 -12 FR diameter
eg. silastic 8 FR
Smaller, more flexible, less irritating
May have weighted tip
Have stylet to assist insertion
Need to be changed monthly
More often used to put fluids into stomach
anti-reflux valve with a
Large bore NG
anti- reflux valve
- prevents
- allows
- when stomach pressure exceeds
- attach ends ___ to ____
prevents gastricrefluxor leakage through the vent lumen of a double-lumennasogastric tube
thevalveallows the passage of air into the vent lumen when atmospheric pressure exceeds stomach pressure
when stomach pressure exceeds atmospheric pressure thevalveprevents flow of fluids through the tube
Attach ends BLUE to BLUE
Indications for an enteral feeding
- Need a functioning and accessible GI tract
- Malnourished or at risk of malnutrition
- To supplement food intake when it is insufficient to meet daily needs
- Unable to ingest oral foods (eg. surgery, head/neck trauma)
- Unwilling to take oral feeds (eg. prolonged anorexia)
- Upper GI tract is impaired (eg. esophageal cancer)
- Dysphagia (eg. CVA, multiple sclerosis, ALS)
- Critical illness (eg. severe burns)
- Malabsorption disorders (eg. crohn’s disease)
- Decreased LOC, coma
complications of enteral feeding
8
*Refeeding syndrome
*Aspiration
- Metabolic problems (eg. deficiency or excess of electrolytes, vitamins, trace elements, and water)
- Over-hydration
- Hypo/hypernatremia
- Tube dislodgement
- Infection
- GI side effects (nausea, abdominal bloating, cramps, regurgitation, diarrhea, constipation)
re-feeding syndrome occurs in
previously malnourished patients who are fed with high carbohydrate loads.
carbs in feeds can cause
a large increase in the circulating insulin level. This results in a rapid and dramatic fall in phosphate, potassium and magnesium - with an increasing extracellular fluid (ECF) volume.
as the body tries to switch from
from catabolic (starvation mode) to using exogenous fuel sources
- there is an increase in oxygen consumption
- increased respiratory and cardiac workload.
- Demand for nutrients and oxygen may outstrip supply.
- can lead to multiple organ failure; respiratory and/or cardiac failure, arrhythmias, rhabdomyolysis, seizures or coma, red cell and/or leukocyte dysfunction.
return of enteral feeding in the gut can cause
be intolerance to the feed, with nausea and diarrhea.
feeds should be started
started slowly and the electrolytes closely monitored and adequately replaced to avoid these problems developing.
Aspiration Risk Factors (for all feeding tubes)
- Head of bed less than 30 degree angle
- Impaired level of consciousness (eg. sedation)
- Neurological deficits
- Poor oral health
- Mal-positioned feeding tube
- Gastroesophageal reflex
- Age over 60 years
- Delayed gastric emptying
Abnormal Blood Results in Malnutrition:
Decreased albumin/pre-albumin and total protein
Decreased Hgb/Hct (if anemic)
Decreased Iron/components
Decreased lymphocytes (or increased if infection)
Decreased blood glucose
Decreased K+ and calcium (and other electrolyte imbalances)
Decreased BUN and CR (but increased if hypovolemic from dehydration eg. renal failure)
Increased liver enzymes (eg. liver damage)
Decreased serum vitamin and mineral levels
Radiography is for
checking NG placement
safety for NG tube
- DO NOT
- No
- Check
- Elevate HOB ____mins
- Provide
- Tape
- Pin
Lie flat (especially if on feed)
no oral intake unless ordered
check position of NG tube prior to administrating meds
elevate HOB 30-60 mins after enteral feeding
provide oral care if pt unable to do
tape in place to reduce irritation from movement with external measurements visible
pin the gown to prevent pulling
potential complications
Aspiration
Abdominal pain, discomfort, nausea
Tissue trauma
Patency of tube can become compromised
Dehydration (r/t NPO status - NG losses replacement usually done with IV fluids (big risk if on suction
assessment prior to insertion
Previous nasal surgery?
Nasal septal deviation
Gag reflex
Patency of nares
Patient cooperation
Check canister and tubing are
securely connected and free of kinks and tension
Assessment and nursing care of NG
- suction
- amount and quality of
- check
- check
- check
- assess
- assess
- irrigation
- position
- provide
- monitoring
- ensure
- ensure
- assess
- confirm
Suction set to prescribed pressure/rate
Amount and quality of gastric contents/residuals
Check canister and tubing are securely connected and free of kinks and tension
Check equipment for functioning
Checking for placement, length changes
Assess oral health, sore throat, irritation, lip and mouth dryness
Assess abdominal distention, BS, N&V, flatus, BM, tolerance of feeds (if indicated)
Irrigation of tubing as ordered or required
Positioning for comfort
Provide regular mouth care
Monitoring for skin breakdown of nares
Ensure pinned to gown and taped is secure
Ensure no coiling of tubing in back of throat
Assess patient’s ability to speak
Confirm external measurement with permanent felt pen mark is at nare
NG insertion procedure
assess
prepare
prepare
insert
check
check
- Assess nares - breakdown, occlusions, best inhalation, SpO2 monitoring, VS
- Prepare tube - conform and soften, measure and mark, lubricant, prep pin, prep tape
- Prepare patient - high fowler’s, basin, blue pad, glass of water with straw basin, moisten mucous membrane, chin tucked slightly down
- Insert tube - advance with swallowing, tape to nose and cheek, pin to gown
- Check back of throat to see that tubing has gone down and not coiling
- Check placement, complete assessment, initiate suction or feed (after xray)
In case of severe/continued gagging/coughing, signs of respiratory distress or decreased SpO2,
STOP. This may indicate that the tube is malpositioned in the airway. Withdraw the tube and reassess the patient. Do not attempt reinsertion until patient respiratory pattern and oxygenation return to baseline
how to measure NG length for insertion
nose to earlobe to xiphoid plus 15 cm
insertion procedure
- slowly
- pause once
- wait until
- in case of severe
- DO NOT
Slowly insert tube into nostril along nasal floor slowly rotating until it reaches nasophayrynx
Pause once resistance is felt. Coughing or gagging may ensue
Wait until gagging subsides and ask patient to swallow water
In case of severe gagging of coughing, signs of respiratory distress or decreased SpO2, STOP. This may indicate the tube is malpositioned in the airway. Withdraw, reassess and do not reattempt until patient’s respiratory pattern has returned to baseline
DO NOT LET GO until it is secured in place
placement can be checked by
- assessing stomach secretions, clear, colorless or ,yellow or green
- injecting air into NGT while auscultating stomach, flush tube with 20 mL or air using 20-60 mL syringe, whooshing sound
- must be confirmed with X ray prior to feeding/med initiation
Nasal bridle
Additional training is required before inserting/ removing a nasal bridle
Using a nasal bridle is an option for securing an NG tube.
Useful for clients that have difficulty maintaining the tube
NG removal procedure
- check orders
- apply blue pad, remove tape and unpin from gown, pt must sit upright with head flexed slightly forward
- my instill 50 ml of water or air into NG to prevent aspiration 30-60 min. prior to removal
- instruct pt to take deep breath and hold (closes epiglottis)
- remove in smooth fluid motion
- inspect tip
- provide oral and nasal care
- document procedure
documentation
NG
- Size, type and length of tube
- External length measurement and securement
- Confirmation of placement done
- Suction rate and characteristics of output
- Type and rate of enteral feeding
- Assessments performed (abdomen, GI, distention, which nare used, tolerance if feeds)
- Patient’s tolerance of procedure (insertion or removal)
ins and outs
Must be documented on In/Out
Characteristics of contents and any procedures on nurses notes
open passive drain systems uses a
soft flexible rubber tape to maintain an opening in tissue to prevent build up of fluid
use safety pin so doesn’t go back into skin
ex. penrose
closed systems
withdraw fluid and it is collected in resevoir
perforated silastic tube is placed in surgical opening during surgical procedure
example of closed system
ho wmuch they hold
hemovac (500 ml)
JP (100 ml)
Removal of Jackson Pratt and Hemovac drain
Shortening and removal of Penrose drain
must be
student SOP
always be directly supervised by a Registered Nurse
leave post op dressing intact for
24-48 hours unless otherwise ordered
JP & Hemovac Emptying
- gradually
- empty
- maintain
- cleanse
- re
- secure
- note
- document
Gradually reduce the charge [pressure] of the drain, face away
Empty contents into a specimen container
Maintain sterility of port
Cleanse port with alcohol
Re-charge and close port
Secure device to gown with safety pin hanging below wound
Note characteristics - amount, color, consistency, odor
Document procedure
JP & Hemovac Removal
- requires
- empty
cleanse
remove
stabilize
have
smoothly
apply
observe
cleanse
cover
assess
document
Requires physician order to be removed, may be for post op timing or amount of drainage (i.e. POD2, or when <30ml/24hr)
Empty drain and leave uncharged
Cleanse wound first, then drain site starting at insertion site and working away
Remove suture if in place
Stabilize skin over drain insertion site with 4x4 gauze
Have the patient take a deep breath and slowly exhale
Smoothly remove drain with exhale in a steady motion
Apply pressure over drain site for 2 minutes
Observe that end of drain is intact
Cleanse drain site when removing 4x4 gauze
Cover with sterile dressing
Assess site dressing 30 minutes after removal for dressing dry and intact or shadowing
Document procedure
penrose drain shortening
Shortening amount and timeline will be ordered by the physician
Set up sterile field with added sterile scissors, safety pin and suture blade
Pull penrose out as per shortening order ( ie. 1 inch per day)
Insert sterile safety pin at new length and cut 2 cm above new pin site
Apply Y dressing around tube site, secure covering dressing
documentation for penrose shortening
Wound assessment
Characteristics of drainage on old dressing
Wound care provided
Shortening length of penrose drain
Type of dressing applied
Patient tolerance of procedure
stages of wound healing
hemostasis
inflammatory
proliferation
remodeling
Dr. orders read: RL @ 100mL/h
Replace ½ of NG losses > than 200 mL with Ringer’s Lactate
Over the shift the patient has 625 mL of fluid loss out their NG. You need to calculate how
much fluid to add onto the next 12 hour shift to replace the fluid loss.
117.7 ml/hr
Patient has TPN running and an NG or ileostomy which has output
Dr. orders read: TPN + RL =125 mL/h
Replace ostomy (or NG) losses 1:1 with RL for volumes above 500mL/shift
The patient had a loss of 720 mL at the end of the shift then you would do the following
TPN running at 66
77.3
position for insertion of NG tube for unconscious patient
laterally on right side
optional ways to check NG tube placement
- check bilirubin stomach should be 5-7
- check pH: 1-5
- inject 10-30ml or air and listen for wooshing
if salem sump tube is used attach a
and place
anti reflux valve to vent port and position above the waist
if felt resistance when inserting tube
relubricate
insert in other nare
steps for removing NG tube
- client in semi fowlers or fowler
- instill 15 ml of water 30 mins prior
- tell pt to take a deep breath in and hold
- withdraw tube
- check intactness
