Skills: Airway/NG/Ostomy

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  1. What is an Ostomy?
    surgically formed opening into the abdominal wall to allow for fecal elimination
  2. Nursing Objectives for pt care with an ostomy:
    • -to give physical and psychological support to the patient (and their family) with an ostomy
    •       *encourage the pt to participate in care and to look at the ostomy
    •       *keep the skin around the stoma site clean and dry
    •       *keep the patient free from odors as much as possible
    •       *maintain appropriate intake and output
    •       *patient teaching
  3. At what point do you empty the ostomy bag?
    1/3 to 1/2 full with stool or air
  4. Emptying Procedure for the Ostomy:
    • -safe entry
    • -waterproof pad under ostomy bag
    • -hold end of pouch up
    • -remove clamp
    • -fold end of bag over like a cuff
    • -empty contents into collection container
    • -use squeeze bottle to squirt water in pouch to rinse it out
    • -use tissue to wipe lower 2 inches
    • -uncuff end and apply clamp
    • -patient may use some sort of deodorizer
  5. How often should an ostomy bag be changed to prevent skin breakdown?
    every 3-7 days
  6. Procedure for Changing Ostomy Bag:
    • -ID patient
    • -Wash hands/don gloves
    • -Explain procedure
    • -Put bed to good height
    • -Waterproof pad under patient
    • -Clean area with soap and water
    • -Pat dry
    • -Assess stoma
    • -Apply skin barrier
    • -Measure stoma opening
    • -Cut Hole 1/8 in larger than opening
    • -Use paste to fill in area between appliance and stoma to protect the skin
    • -Snap pouch on
    • -Document appearance of stoma, condition of skin, drainage and how patient tolerated procedure
  7. Principle indication for an NG tube:
    • Functional gastrointestinal tract with suffiecient length and absorptive capacity and the inability to take nutrients through the oral route totally or in part
    •     -impaired swallowing
    •     -major trauma
    •     -burns
    •     -critical illness
  8. An NG tube is not appropriate for someone with ____________
    A poor gag reflex
  9. In addition to being used for nutritional purposes, it can also be used for:
    decompression, compression, or gastric lavage
  10. Salem Sump
    Large bore NG tube that has the pigtail (air vent) which allows for free, continuous drainage of secretions through the main lumen....
  11. Never use the air vent on a Salem Sump to ____
    Irrigate, Clamp Off, or Connect to Suction
  12. Sengstaken-Blakemore
    Large bore NG tube for compression to stop bleeding
  13. Large Bore Tubes
    Usually used for gastric decompression or removal of gastric secretions and gastric lavage
  14. Small Bore NG Tubes
    used for medication administration and tube feedings
  15. Dobhoff
    Small Bore NG Tube that has a wire stylett that helps guide....used for medication, enteral nutrition.

    *ALWAYS have X-Ray confirmation of placement
  16. Insertion procedure of a NG Tube
    • ID patient
    • Explain procedure
    • Wash Hands
    • Assess Patient
    •    -determine contraindications: polyps, nose bleeds, deviated septum, history aspiration, nasal surgery, anticoagulants, trauma
    •    -inspect nares with penlight
    •    -have patients occlude one nare and breathe through the opposite nare (repeat on other side)
    •    -test gag reflex with tongue blade
    • Gather Supplies
    •     -HAVE SUCTION available
    • Position Pt in HIGH fowlers
    • Raise Bed to Good Working Height
    • Hand Patient Emesis Basin
    • Open Tube
    • Place Water Soluble lubricant on paper
    • Don Clean Gloves
    • Measure Tube
    •     -from Nose to Earlobe to Xiphoid Process
    • Mark tube with piece of tape of indelible marker
    • Lubricate the tube
    • Have pt. extend head back
    • Have pt swallow as you pass the tube
    • Use penlight to check mouth
    • Tape anchor tube in place
    • Be sure air vent is above level of stomach
    • Return bed to lowest position 
    •     -keep HOB between 30-45 degrees
    • Provide oral hygiene every 2-4 hours
    • Document
  17. Ways to verify placement of NG tube
    • X-ray 
    •     -needs doctor's order, but is most reliable

    Assess lung sounds

    • Insert Air and assess for bowel sounds
    •     -not as reliable, but inserting air may make it easier to withdraw gastric contents

    • Withdraw and visualize gastric content
    •     -grassy, green/brown, clear or mucusy

    Check Ph < 5

    • CO2 detector
    •      -if it is positive you are in the lungs

    • Put end of tube into glass of water and watch for bubble
    •     -proven unreliable

    Length of tube should remain constant
  18. Signs of Distress in a patient with NG tube
    Gasping, Coughing, Cyanosis, Inability to speak or hum
  19. If an NG tube is for gastric decompression, hook to suction setting between ______ (usually intermittent to prevent it from getting adhered to stomach wall)
    20-40 mm Hg
  20. Irrigation of NG tube is typically done _____
    Every 4 Hours
  21. Irrigation Procedure for NG Tube
    • ID patient
    • Elevate HOB
    • Wash hands/don gloves
    • Pour irrigation solution into container
    • Disconnect from suction
    • Measure length of exposed tube
    •     -this allows you to observe for a change in the external length
    • Aspirate stomach contents and check pH
    • Insert 30 ml of irrigating solution by gravity or pushing gently
    • Withdraw manually or reconnect to suction
    • Not characteristics of return solution
    • Can inject air into air lumen to be sure it's clear
  22. Routine care of NG tube patients:
    • Frequently inspect nares for irritation, redness, breakdown or ulceration 
    •      -can lubricate around nares
    • If nare is breaking down, remove NG tube and place in other nare or find another route
    •     -check with provider
    • Provide frequent mouth care
    •     -encourage pt. to brush teeth and lubricate lips
    • If throat hurts, get analgesic spray
    • Check hospital policy for how often to:
    •      -check placement (usually 4-6 hrs)
    •       -check residual
    •       -flush tubing (may modify based on fluid restrictions)
    •       -change dressing
  23. Process of REMOVING NG tube
    Assess for bowel sounds, flatus and return of appetites

    Place towel or waterproof pad over pt chest

    ID patient/Explain procedure

    Wash Hands/Don Gloves

    Raise bed to working height

    Disconnect from suction

    Untape from nose and detach from gown

    If the NG has a balloon be sure to deflate it

    Hospital policy may or may not have you check for residual

    Have pt take deep breath and hold it

    Pinch and remove tube

    Inspect tube

    Offer Mouth Care

    Observe pt for gastric distention, N/V
  24. Types of Enteral Feedings
    NG tube, PEG tube, J-tube, GI tube
  25. Purpose of Enteral Feedings
    Used when nutrients need to be given directly into the GI tract and bypass mouth/swallowing
  26. Gravity Feeding (intermittent feeding) Process:
    Attach barrel/syringe or end of feeding bag to feeding tube

    Elevate approximately 12in. above stomach and allow to go in by gravity until amount ordered has gone in (the height of the syringe will regulate how fast or slow it goes in)

    Flush with 30ml of water

    Disconnect from tubing and cap tubing

    Have Patient Sit Upright for 60 Minutes After Feeding is Completed!
  27. How often should you check the placement of a tube and gastric residual?
    every 4-6 hours
  28. Be sure the Head of Bead is at least _______ at all times with patients that have tubes!
    30-45 degrees
  29. Pros/Cons of Continuous Feedings:
    • Pros:
    •    *Gradual introduction of formula into GI tract
    • Cons:
    •    *Limits mobility, needs pump increasing cost, increased risk for reflux and aspiration
  30. Pros/Cons of Intermittent or Bolus feedings
    • Pros:
    •    *Resemble a more normal pattern of intake and allows for more freedom of movement
    • Cons:
    •    *May cause overdistention, leading to nausea, diarrhea, cramping, or even dumping syndrome
  31. When is Cyclic feeding appropriate/best?
    When administering food for a portion of a 24 hour (usually during the night allowing for freedom during the day)
  32. Immediate Flags/Concerns:
    • -if a pt is gasping for air or unable to speak
    • (Remove tube immediately and assess status/VS)

    • -if you are unable to flush the tube
    • (try to reposition the patient and try to inject air which may move tube away from stomach wall)

    • -Clogging
    • (prevent by flushing with cranberry juice, cocacola, meat tenderizer or WARM WATER)
  33. Serious harm/death can result in patients with tubes if:
    • Misconnection Occurs
    • The tube is misplaced/displaced
    • Aspiration occurs
    • GI intolerance related to formula contamination
    • Drug-nutrient interactions
  34. As nurses, we must be diligent in _____ when it comes to tubes:
    • Ordering -- right formula, rate, tube
    • Preparation -- aseptic technique
    • Delivery -- correct tube placement and HOB elevated
    • Monitoring -- change tubing every 24hr, check residual
  35. Review of Medications through NG tube:
    • Can put liquid medications or medications that can be crushed and combined with liquid
    • down the tube.

    Make sure medication is compatible with formula

    Place patient in high-fowlers position.  Keep HOB elevated for at least 1 hour after medication is administered

    Verify placement of tube confirming with at least 2 methods

    If the tube is connected to suction disconnect the tube and leave it clamped for 20-30 minutes after administering the medication.

    If the patient is on continuous tube feeding, then clamp for 30 minutes, flush,  give medication, flush, resume feeding 30 minutes to 1 hour after.  If medication is not compatible than a minimum of 30 minutes to hold feeding is a must!

    Give each medication separately.

    Use syringe as a funnel

    Flush with water before, between and after each medication.  The amount is determined by patients age, size, medication order and hospital policy.

    Adults are usually 30 ml of water

    Document medication and flush as part of intake.
  36. GI Tube Care:
    Checking placement by measuring tubing that is outside abdomen

    • Care of the insertion site would include:
    • ◦Clean around site with warm water or ½ strength H2O2

    ◦If external disk rotate 90° once a day

    ◦If drainage can use zinc oxide  to prevent breakdown

    ◦Use split gauze to absorb secretions

    ◦Check routinely for pain, redness, drainage, if disk is digging into skin
  37. Purpose of Naso-pharyngeal suctioning:
    Done to provide comfort by clearing the air passages and decreasing the work of breathing *helps improve oxygenation

    Used with patients that are unable to remove secretions with coughing
  38. Procedure for Naso-Pharyngeal Suctioning:
    Verify doctor’s orders

    Wear PPE

    You may have to pre-medicate the patient with pain meds

    ID patient

    Explain procedure

    Put bed to good working height

    Assess nasal passages.  Check for history of problems such as deviated septum, polyps

    • Assess lung sounds- suctioning should only be done if secretions have accumulated or
    • there are adventitious breath sounds

    Wash hands and don PPE  (gown, mask)

    Position patient

    Place waterproof pad across patient’s chest

    Verify suction is working and set at 80 -120 mm Hg [too high pressure can cause trauma]

    Sterile procedure: Your dominant hand will remain sterile and your non-dominant hand will be your clean hand

    Open package. Remove container and pour saline in container (a little different from video)

    Don sterile gloves

    Remove suction catheter from package

    Secure catheter to tubing with non-dominant hand

    Lubricate tubing in normal saline and check suction by occluding port

    If patient is on oxygen have them take a few deep breaths, then remove oxygen using non-dominant or clean hand

    Measure tubing from earlobe to nostril without touching it to patient or insert into nare 6-8” WITHOUT APPLYING SUCTION

    Apply intermittent suction with thumb and rotate catheter while withdrawing for a maximum total time of 10-15 seconds

    If on oxygen, allow patient to breath in oxygen in between passes

    Clear tubing with normal saline and repeat, waiting 30 seconds – 1 minute in between passes (can wrap tubing around hand between passes)

    Do not go down more than 3 times

    Reapply oxygen

    Dispose of supplies

    Assess lung sounds

    Document before and after lung sounds, characteristics and amount of secretions, how patient tolerated procedure
  39. Procedure for Endotracheal Suctioning:
    Same as Nasopharyngeal Suctioning EXCEPT:

    • ◦To hyper-oxygenate your patient, at the beginning and in between passes, you will
    • need to bag them rather than them taking deep breaths so you will need an ambu bag
    • giving 3-6 breaths

    • ◦When inserting catheter you will go until you meet resistance or patient begins to
    • cough, pull back slightly [approx 1”], then start suctioning as you withdraw the catheter (usually 4-5”)

    ◦Patient may need to rest for 1 minute in between passes

    • ◦Place oxygen device back over patient stoma rather than face
  40. Things to consider for a patient with a Trach:
    -A patient that has a trach is unable to speak (consider their inability to communication and keep communication tools close at hand)

    -Make sure Call bell is in reach

    -Offer frequent reassurance

    -Try to anticipate patient's needs
Card Set:
Skills: Airway/NG/Ostomy
2014-01-28 16:27:41

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