Essential Nursing Care Bp Skills Test

Front 1

Taking BP measurement

Back 1

taking blood pressure steps
- gain consent
-perform hand hygiene
-ensure patient has not smoked or taken caffeine in the last 30 min
-locate brachial artery
-align bp cup with it.
-find brachial pulse (tell patient to flex arm if pulse can't be felt)
-pump up sphygmo until pulse cannot be felt
-remember that number say the number is the estimated systolic pressure
-pump up to 30mm of mercury higher than the reading u got
-say the full reading. higher over lower reading. eg the reading is 120, which is the systolic pressure, over 80, the diastolic pressure.
-document and report if blood pressure is abnormal but here it is normal (if between 90/50 and 120/90 mmHg)

Front 2

NGT feeding

Back 2

NASOGASTRIC TUBE (NGT) FEEDING STEPS

1. Check the documentation and plan to verify identity of patient and procedure to see what’s required of the feed

2. Explain procedure and gain consent, Ensure patient is sitting in semi fowler position to aid absorption.

3. Ensure patient is comfortable and Gather equipment and perform hand hygiene

4. Begin procedure, i will to first put a “bluey” to protect the patient and the bed linen and put on my non-sterile gloves (because of body fluid involved in procedure)

5. Check the location of NGT

6. Take end of the tube and pinch it off (kink it) to prevent air backflow which could cause discomfort to patient

7. Remove the cap and replace it with a syringe. Pinch*?1.42 and withdraw enough* aspirate

8. Aspirate contents to check location. (expecting the stomach contents to be a grassy green colour)

9. Pinch it off and replace cap/nozzle (previously removed) to prevent spillage/ backflow of air

10. Check the pH of aspirate. - If tube is in the stomach, i expect the ph to be 1-4 since the stomach is acidic. If it is over 6, it would suggest that tube is not in the stomach but in the wrong place. OVer 7? - may be respiratory tract
11. Checking the strip against the container, pH is appropriate so NGT is actually in the stomach
12. Under normal circumstances, i would continue to aspirate all the contents of the stomach to determine its residual volume. - I
If it’s > 100ml or more than half of last feed, it would show that patient is not absorbing appropriately and seek advice from senior nurse and not proceed with the feed.
If its normal quantity <100ml or less than half of last feed, i’d replace stomach contents and continue with procedure according to the care plan

Actual procedure
13. Remove plunger from syringe because its a gravity feeding (not actually forcing contents into stomach could be problematic)
Plan has said that before the feed there is a 10ml water flush, the feed is 10ml and post feed, another 10ml of water flush (to ensure that tube is clear)

14. I would pinch tube again to prevent airflow which could cause discomfort. Remove cap and attach syringe. Keep pinching and attach 10 ml of water. Then unpinch and hold it up allow water to drain via gravity. (if difficult, could use the plunger to gently massage the top of the tube. ) Then pinch it off to prevent air flow

15. Now i have 10ml of feed as per the plan, which i would put into the syringe, unpinch and let flow by gravity (could massge with plunger if it doesnt flow)
16. 10ml of water post feed to ensure tube stays clear, unpinch and allow to flow. As it’s a gravity flow, the higher i hold the tube, the greater the gravitational force acting on it and the faster the fluid would flow. Must adjust position accordoingly so that flow is at appropriate rate
17. Make sure that feeds are warmed up because cold feeds can cause cramping and discomfort to patient
18. If at any stage during the procedure, the patient is demonstrating cramping on discomfort or showing any signs of pain, choking or coughing, (suggests that tube is going into lungs) I would stop the procedure immediately

19. Once feed is finished, pinch tube and disconnect syringe to prevent discomfort, put cap back on.
20 Before leaving the patient, i’d ensure that the patient remains in semifowlers position (or at least 30 degs) so that they are able to comfortably digest. Ensure that ive removed my equipment and disposed of it appropriately and would document appropriately about what patient had for their feed that they were comfortable and there were no complications

Front 3

bp

Back 3

taking blood pressure steps
- gain consent
-perform hand hygiene
-ensure patient has not smoked or taken caffeine in the last 30 min
-locate brachial artery
-align bp cup with it.
-find brachial pulse (tell patient to flex arm if pulse can't be felt)
-pump up sphygmo until pulse cannot be felt
-remember that number say the number is the estimated systolic pressure
-pump up to 30mm of mercury higher than the reading u got
-say the full reading. higher over lower reading. eg the reading is 120, which is the systolic pressure, over 80, the diastolic pressure.
-document and report if blood pressure is abnormal but here it is normal (if between 90/50 and 120/90 mmHg)