N210 Week 3 Lab NGT & Elimination/Bowel/Bladder

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N210 Week 3 Lab NGT & Elimination/Bowel/Bladder
2015-10-12 15:15:08
N210 Week Lab NGT Elimination Bowel Bladder
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  1. 1. Discuss reasons for nasogastric intubation
    • • Is inserted through the nose and into the stomach
    • • Gaining access to stomach and its contents
    • • Once NG tube is placed, it can deliver food and medicine directly to the stomach or remove substance from it
    • • NG tubing is often used to deliver food and medicine to a patient when they are unable to eat or swallow
    • • NG tubing may be used to remove poisonous substances and remove contents of the stomach for testing or analysis
  2. Describe the process of nasogastric tube insertion and removal including equipment needed. (Taylor pg. 2353)
    • • Nasogastric tube insertion: Look at Video Skill Notes
    • • Removal of Nasogastric tube: Need tissues, 50-mL syringe, non-sterile gloves, additional PPE, stethoscope, disposable plastic bag, bath towel or disposable pad, normal saline solution for irrigation (optional), emesis brain
    • Check medical record for the order for removal of the NG tube
    • Perform hand hygiene and put on PPE
    • Identify patient
    • Explain procedure to patient and why this intervention is warranted, few moments of discomfort
    • Maintain privacy and lift bed to working level with a 30-degree position.
    • Place disposable pad across the patient’s chest
    • Give tissues and the emesis basin to the patient
    • Put on gloves
    • Discontinue suction and separate the tube from the suction.
    • Unpin the tube from patient’s gown and carefully remove the adhesive tape
    • Check placement and attach syringe and flush with 10 mL of water
    • Clamp tube with fingers by doubling tube on itself
    • Instruct the patient to take a deep breath and hold it. Quickly/carefully remove the tube while the patient holds breath
    • Coil tube in the disposable pad as you remove it from the patient
    • Dispose of the tube per facility policy.
    • Remove gloves. Perform hand hygiene
    • Remove equipment and lower bed
    • Put on gloves and measure the amount of nasogastric drainage in the collection device. Record the measurement on the output flow record, subtracting irrigant fluids if necessary
    • Add a solidifying agent to the nasogastric drainage and dispose of the drainage according to facility policy
    • After tube is removed, provide for oral hygiene to remove disagreeable tastes and odors
  3. Describe various methods to check placement of a nasogastric tube
    • • Ensures that the tip of the tube is situated in the stomach or intestine, preventing inadvertent administration of substances into the wrong place
    • • An old technique of auscultation of air injected into a feeding tube has provide unreliable and may result in tragic consequences if used as an indicator of tube placement
    • • Radiographic Examination
    • • This is the standard procedure to verify initial placement of a feeding tube
    • • This however, exposes the patient to radiation, must be interpreted by a physician, are costly if done on a routine basis and may be inaccessible
    • • Only confirms the position of the tube at the time it was taken so the tube may have been moved at any point thereafter.
    • • Placement must be checked frequently while the tube is in place
    • • Measurement of Aspirate pH and Visual Assessment of Aspirate (Taylor pg. 1226-1227)
    • • Measuring with pH of the aspirate
    • • When continuous feedings are in use, pH becomes less helpful because the nutritional formula buffers and the pH of gastrointestinal secretions
    • • Aspiration of fluid thought the feeding tubes is difficult for smaller diameter tube because they are less rigid. They may be more likely to collapse when negative pressure is applied during aspiration. More than likely, the difficulty is from the blocked tube.
    • • If repeated instillations of 30 mL of air and repositioning prove ineffective, tube placement should be checked by radiograph after obtaining an order from the primary care provider
    • • Measurement of Tube Length and measurement of Tube Marking
    • • Before each feeding, check tube length and compare findings with the initial measurement in conduction with pH measurement and visual assessment of aspirate.
    • • Any increase in length of the exposed tube may indicate dislodgement
    • • Marking the tube with an indelible marker at the nostril and then assessing this marking each time the tube is used ensure that the tube has not become displaced
    • • Carbon Dioxide Monitoring
    • • To determine nasogastric tube position and/or dislodgement has been evaluated
    • • This involves the use of a capnograph to detect the presence of carbon dioxide which indicate tube positioning in the patient’s airway
    • • However, the carbon dioxide sensor cannot determine where a feeding tube’s tip ends in the GI tract
    • • Confirming Nasointestinal Tube Placement
    • • After an initial x-ray for placement, the nurse can validate that the tube is still in the small intestine by checking the pH of the aspirate (pH is greater and equal to 6 and bi-stained, ranging in color from light to golden yellow or brownish-green)
  4. Discuss nursing interventions related to promoting patient comfort and maintaining a nasogastric tube.
    • • Promoting Patient Safety
    • • Check tube placement before administering any fluids, medications, or feeding
    • • Check gastric residual (feeding remaining in the stomach) before each feeding or every 4-6 hrs during continuous feeding
    • • Assess the abdomen for abnormalities. Assess for bowel sounds at least once per shift to check for the presence of peristalsis and a functional intestinal tract.
    • • Make sure patient is upright as possible during feeding to 30 degrees
    • • Prevent contamination during enteral feedings by maintaining the integrity of the feeding system and using proper technique. Closed systems consist of sterile, prefilled, ready to hang container, reduce the opportunity for bacterial contamination of the feeding formula. An open system exists when formula from a can or bottle is added to a feeding set up
    • • Medications may be administered through a feeding tube, but never give them while a feeding is being infused. Administer liquid forms of medications whenever possible. Never add medications directly to the formula; some drugs become ineffective when mixed with feeding formulas; medications mixed in feeding formulas may cause clogging of the feeding tube. It is very important to flush the tube with water before, between, and after the administration of medications
    • • Monitoring for Complications
    • • Prevent tubs from being clogged or obstructed
    • • After checking placement, flush tube with 30 to 50 mL of water before and after each feeding or introduction of medications, at least every 4 hours during a continuous feeding, and after aspirating a tube for gastric contents. After flushing the tube, be sure to document the amount on the intake and output record. Use feeding pump to prevent clogging. If an occlusion occurs, use a 60-mL syringe containing 30 to 60 mL of warm water to unclog the tube
    • • Providing comfort measures
    • • Irritation to nasal and throat mucosa and drying of the oral mucous membranes
    • • Administer oral hygiene frequently (every 2-4 hours)
    • • Keep nares clean
    • • Help control local irritation from the tube in the throat
    • • Encourage the patient to verbalize concerns about tube feeding
    • • Ensure that the tube is secured to the patient’s nose and gown to prevent tension and tug on the table, which causes trauma to the nares and potential displacement.
    • • Providing Instructions
    • • Provide patient and family with individualized instructions in written form as a reference for the patient and caregivers
    • • Information about the administration of feedings, operation of pump, rate, checking tube placement, and what happens when dislodged
    • • Care of tube insertion site
    • • Proper preparation, cleaning, disposable equipment
    • • Emergency phone number
    • • Arrangements of follow-up from home health care nurse as soon as possible after discharge
  5. Compare and contrast the Salem sump and Levin gastric tubes (Taylor pg.1370)
    • • Salem Sump
    • o Double-lumen tubes
    • o One lumen empties the stomach and the other provides for a continuous flow of air. The airflow lumen controls suction by preventing the drainage lumen from pulling stomach mucosa into the tube’s openings and irritating the stomach lining.
    • • Levine Gastric Tube
    • o Common single-lumen tube
    • o Lacks a venting system, and mucosal damage can occur when suction are applied continuously. So it is applied intermittently
  6. Discuss the steps to discontinuing an nasogastric tube
    o Refer to #2 REMOVAL OF NGT TUBE
  7. Discuss reasons for nasogastric and gastric intubation (Internet source)
    • o Nasogastric and gastric intubation is needed if patient…
    • • is unable to meet nutritional needs through oral intake of an adequate diet
    • • is too weak to eat food orally
    • • is comatose
    • • has neck or facial injuries, or recent surgeries
    • • Is breathing on a mechanical ventilator
    • • Is a premature infant
  8. Describe the process of administering a continuous and intermittent nasogastric and gastrostomy tube feeding. (pp. 1229 Taylor)
    • Continuous Feeding
    • • Allow gradual introduction of the formula into the GI tract, promoting maximal absoprtion
    • • Require use of an external feeding pump, which limits pt. mobility and increases cost
    • • Controversial because of the risk for reflux and aspiration
    • Intermittent Feeding
    • • Deliver at regular intervals in equal portions
    • • Introduces the formula gradually over a set period of time via gravity or a feeding pump
    • • Resemble a more normal pattern of intake and allow patient freedom of movement between feedings
    • Gastronomy (tube)
    • • Used for long period nutritional support
    • • Surgically inserted in the stomach (gastro = stomach)
    •  Less likely to regurgitate and aspirate if NG tubes were used
  9. Demonstrate the process of administering a water bolus via an NGT or gastrostomy feeding tube.
    • (https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000165.htm)
    • Procedure - Bolus Tube Feeding
    • Wash hands.
    • Assess abdomen for distention.
    • Elevate head of bed to at least 30 degrees.
    • Measure residual every 4 hours (if residual is more than 200 ml or other specifically ordered amount, hold for one hour and recheck; if it still remains high notify doctor).
    • Reinstall residual.
    • Insert 60 ml syringe into port and pour feeding product into syringe.
    • Add formula to drain by gravity.
    • Add more formula until the desired amount is infused.
    • Flush with 50 ml (or amount ordered by doctor) of water.
    • Cap the tube.
    • Remain in upright position for at least one hour after feeding.
    • Rinse equipment thoroughly.
  10. Discuss how nasogastric and gastrostomy feedings are measured
    • and recorded
  11. I. as volume of urine increases, pressure increases only slightly
    • II. when pressure becomes sufficient to stimulate nerves in bladder à desire to pee
    • D. Urethra
    • 1. transport urine from bladder to exterior of the body
    • 2. external sphincter is under voluntary control
    • E. Act of Urination
    • 1. urinating is largely an involuntary reflex
    • 2. voluntary control develops as higher nerve centers develop after infancy
    • 3. autonomic bladder: people whose bladders are no longer controlled by brain bc of injury/disease
    • 4. stretch receptors are stimulated as urine collects
    • 1. person feels desire to void
    • 2. bladder fills about 150 to 250 mL
    • 5. if voiding is delayed, bladder continues to fill
    • 1. discomfort may be felt when undue distention occurs
    • 2. urgency to void becomes paramount
    • 6. increased ABD pressure forces involuntary escape of urine
    • 1. i.e: coughing and sneezing
    • 7. urinary incontinence: any involuntary loss of urine that causes a problem
  12. c. pyelonephritis
    • d. ureteral obstruction
    • c. chronic kidney disease
    • a. end result of irreparable damage to kidneys
    • d. chronic renal failure
    • a. caused by conditions such as:
    • a. diabetes
    • b. HTN
    • c. glomerulonephritis
    • e. diseases that reduce physical activity or lead to generalized weakness à interfere with toileting
    • f. fever and diaphoresis à body fluid conservation by the kidneys
    • g. high blood glucose levels à increase urine output secondary to osmotic diuretic effect
    • 6. Medications
    • a. abuse of analgesics cause nephrotoxity; some antibiotics, can be nephrotoxic (kidney damage)
    • b. Diuretics
    • a. prevent absorption of water and certain electrolytes in tubules
    • b. cause moderate to severe increases in production and excretion of dilute urine
    • c. certain drugs can cause urine to change color:
    • a. anticoagulants may cause hematuria (blood in urine)
    • b. diuretics lighten color of urine to pale yellow
    • c. phenzopyridine (Pyridium), cause orange or orange-red urine
    • d. amitriptyline (Elavil) or B-complex vitamins turn urine green or blue-green
    • e. Levodopa (antiparkinson drug), and injectable iron compounds à brown or black
  13. 3. Describe how the nurse would assist patient with toileting, bedpan, urinal, BC, and condom catheter
    • 1. Toileting
    • a. be responsible for noting abnormalities of urinary elimination
    • b. patient may be taught to report abnormalities to nurse and instruct not to flush until checked
    • c. a hat may be placed in toilet to measure urine volume
    • d. assist weakened patients to bathroom
    • e. if any danger of patient falling, remain in attendance
    • f. never lock bathroom door
    • g. have call light within reach
    • 2. Bedpan/Urinal
    • a. male patients confined to bed usually use urinal for voiding and bedpan for defecations
    • b. female patients use bedpan for both
    • c. many patients find it embarrassing and difficult to use maintain patient privacy
    • d. fracture bedpan
    • a. used for people with fractures of femur or lower spine
    • 3. Commode
    • a. can be used for patients who can get out of bed, but not use bathroom toilet
    • b. assisted to it with minimal exertion
    • c. give privacy
    • 4. Condom Catheter
    • a. used as an alternative to an indwelling catheter
    • b. vigilant skin care to prevent excoriation
    • c. remove condom daily and wash penis with soap and water, dry, and inspect for irritation care must be taken to fasten condom securely enough to prevent leakage
    • d. tip of tubing should be kept 1-2 inch beyond tip of penis to prevent irritation to glans area
    • e. maintain free urinary drainage
    • a. prevent tubing from kinking and urine backing up
    • f. position tubing that collects urine from condom to draw urine away from penis
  14. 4. Describe care and management of indwelling catheter and external urinary catheter
    • 1. Indwelling Catheter
    • a. wash hands before and after caring for patient
    • b. clean perineal area thoroughly especially around meatus, daily and after each BM
    • c. cleanse catheter by cleaning gently from the meatus outward
    • d. use mild soap and water or a perineal cleanser to clean perineal area
    • a. rinse area well
    • b. do not use powder and lotions after cleaning
    • c. do not use antibiotic or other antimicrobial cleaners or betadine at urethral meatus
    • e. patient maintains generous fluid intake, unless contraindicated
    • a. helps prevent infection
    • b. irrigates catheter naturally by increasing urine output
    • f. encourage patient to be up and about, as ordered
    • g. note volume and character of urine, and record observations carefully
    • a. note and record amount of urine on patient’s I&O q8h
    • h. do not open drainage system to obtain urine specimens or to measure urine
    • a. if tubing becomes disconnected and sterile closed drainage system compromised, replace!
    • b. when emptying drainage bag, make sure spout does not touch contaminated surface
    • i. teach pt. important of personal hygiene
    • a. emphasize hand washing!
    • 10. promptly report any signs or sympotoms of infection
    • 1. burning sensation and irritation at the meatus
    • 2. cloudy urine
    • 3. strong odor to the urine
    • 4. elevated temperature and chills
    • 1. help pt. take a shower bath if possible
    • a. keep bag lower than the bladder to promote drainage
    • 2. consider EBP to ensure catheter is removed ASAP!
    • 3. change indwelling catheters if necessary
    • B. External Catheter
    • 1. used as an alternative to an indwelling catheter
    • 2. vigilant skin care to prevent excoriation
    • 3. remove condom daily and wash penis with soap and water, dry, and inspect for irritation
    • 4. care must be taken to fasten condom securely enough to prevent leakage
    • 5. tip of tubing should be kept 1-2 inch beyond tip of penis to prevent irritation to glans area
    • 6. maintain free urinary drainage
    • 1. prevent tubing from kinking and urine backing up
    • 7. position tubing that collects urine from condom to draw urine away from penis
  15. 5. State the rationale for measuring and record patient’s urinary output
    • A. accuracy of total fluid I&O from all sources
    • 1. aids in identifying potential alterations in fluid balance
    • 2. essential for planning patient’s nursing and medical care
  16. 6. Discuss use of a “hat” in a commode and gradated cylinder to measure urine output
    • A. accuracy of total fluid I&O from all sources
  17. 4. Describe the care and management of an indwelling catheter and external urinary catheter 1293
    • A. Wash hand
    • B. Wear gloves
    • C. Clean perineal area
    • D. Cleanse the perineal area
    • 1. use mild soap and water to cleanse perineal area
    • 2. do not use powder and lotions.
    • E. Make sure the patient is getting good fluid amount
    • F. encourage patient to be up and about
    • G. note the volume
    • H. teach patient the importance of personal hygiene
    • I. promptly report any s/s help patient take showers, consider evidence practice
  18. 5. State the rationale for measuring and recording the patients urinary output 1272
    • A. Measuring the patients output and intake is an important nursing responsibility.
    • B. Accuracy of the total fluid intake and output from all sources aids in identifying potential alteration in fluid balance and is essential for planning the patients nursing and medical care.
  19. 6. Discuss the use of a hat in commode and graduated cylinder to measure urine output pg1274
    • A. Specimen hat is a container that is placed anteriorly on the toilet, underneath the seat.
    • B. Used to collect urine
    • C. Graduated Cylinder makes it possible to have accurate urine output records
  20. 7. Describe the process of emptying a foley catheter drainage bag PG 1273-1274
    • A. Put on gloves
    • B. Place calibrated device beneath the urine collection bag at the bedside.
    • C. To prevent the spread of infection, patients should have their own calibrated measuring device,
    • D. Place the drainage spout from the collection bag above but not touching the measuring device, step 4 all the urine to flow from the collection bag into the measuring cup
    • E. finally re-clamp the drainage tube wipe the spout of the tube with an alcohol pad.
  21. 8. Describe how the collection of the following urine specimens are obtained and give the reason why they are collected.. Midstream, 24 hour and indwelling catheter 1274-1275
    • A. Midstream as known as clean catch is required in most health agencies.
    • B. This means that the patient voids in the toilet then discards a small amount of urine continues voiding in a sterile specimen container to collect the urine, stops voiding then finally finishes off urinating the rest in the toilet.
    • C. 24 hour For some lab tests a 24 hour UA is needed.
    • 1. The patient and the rest of the staff understand the importance of this.
    • 2. Post a sign on the patient’s bathroom door as it will be helpful not to discard.
    • D. Initiate and write the time the urine was collected.
    • 1. Sometimes the urine of each collection might be placed in different containers or it could be in one.
    • 2. The lab will let you know if preservative is used to retard decomposition and whether the specimen is to be refrigerated or kept in ice.
    • E. Indwell catheter you could either catheterize the pt or by taking urine from the indwelling catheter that is already placed.
    • F. If collecting it from the indwelling catheter obtain it from the catheter itself by using the special port.
    • 1. Don’t use the urine from the bag it may not be fresh.
    • G. Gather equipment including a syringe antiseptic swab, sterile container gloves and possibly a clamp.
    • H. A urine culture will need 3 ml but a urinalysis requires 10ml.
    • I. Wear gloves for prevention.
    • J. If the urine is not in the tube clamp and come back 30 minutes later.
    • K. Clean the port with the swab attach syringe to the port and aspirate.
    • L. Then transfer it to the appropriate container.
    • M. Make sure patient name date and time collected.
  22. 1. rectum becomes distended by fecal mass
    • a. primary stimulus for defecation reflex
    • 3. rectal distention à increase in intrarectal pressure = muscles to stretch = urge to eliminate
    • 4. if urge to defecate is ignored, defecation often can be delayed voluntarily
    • 5. eased by flexing thigh muscles = increases ABD pressure
    • 6. bear down, the increased pressure in ABD and thoracic cavities = decrease blood flow = low output
    • 1. this act may dangerously elevate blood pressure in a person with HTN (Valsalva maneuver)
  23. 2. Describe characteristics of normal bowel elimination and stool
    • A. Volume
    • 1. Variable
    • 1. volume of stool depends on amt. the person ate and nature of diet
    • B. Color
    • 1. Infant: yellow to brown
    • 2. Adult: brown
    • C. Odor
    • 1. pungent; may be affected by foods ingested
    • D. Consistency
    • 1. soft
    • 2. semisolid
    • 3. formed
    • E. Shape
    • 1. formed stool is usually 1 in. in diameter and has tubular shape
    • 2. may be larger or smaller, depending on condition of colon
    • F. Constituents
    • 1. waste residues of digestion:
    • 1. bile
    • 2. intestinal secretions
    • 3. shed epithelial cells
    • 4. Bacteria
    • 5. inorganic material
  24. 3. ID nursing interventions for patients with diarrhea or constipation
    • A. Diarrhea
    • 1. answer patient’s call light immediately
    • 2. remove cause of diarrhea
    • 1. discontinue meds that cause diarrhea
    • 3. give special care to region around anus where skin irritation is common
    • 1. keep area clean and dry
    • B. Constipation
    • 1. combination of high fiber foods (20-35g), 60-80z of fluid, and exercise = controls constipation
    • 2. use laxatives that induce emptying of intestinal tract
  25. 4. Discuss the steps for the following procedures: removing fecal impaction; rectal suppository, administering a large volume enema; administering a small volume enema.
    • Steps for following procedures
    • • Removing Fecal Impaction: 1368
    • • Rectal suppository: 1366
    • • Administering Large Volume Enema: 1378
    • • Administering Small Volume Enema: 1366
  26. Identify nursing interventions if signs and symptoms of vagal response occurs (1369)
    • • Monitor Bowel sounds
    • • Encourage adequate fluid intake
    • • Teach patient about specific foods that are assistive in promoting bowel regularity
    • • Monitor bowel movements: frequency, consistnecy, shape, volume and color
  27. Describe how stool specimens are collected and give the various reasons why they are collected (1355)
    • How:
    • A. void first
    • B. Defecate int required container
    • C. Avoid contaminating outside rim of container with feces
    • D. Send stool for lab testing immediately or refrigerate unless contraindicated
    • Why:
    • • Suspection of infection from bacteria, virus, parasite, fungi
    • • Occult blood: blood hidden in the specimen
    • • Assess for pinworms that may migrate to there rectal areas