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9 Cards in this Set
- Front
- Back
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Describe the method of inserting a nasogastric tube including position of the head during insertion.
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•Gather equipment – tube, tape, gloves, water-based lubricant, glass of water & straw, 20-50 ml syringe w/adapter, basin, blue pad, stethoscope, safety pin, rubber band
•Position patient in high fowler’s •Explain procedure to patient and tell them to raise their hand if they have trouble during procedure to alert you. •Assess nares for any obstruction and select the nostril that has greater airflow •Measure – nose to ear to xiphoid – put piece of tape on it •Lubricate tip of tube •Tip patient’s head backwards, aim for the ear •Once past the nasopharynx, flex patient’s neck forward, opens esophagus •Continue to pass tube, can swallow ice water simultaneously if swallowing reflex intact •Tape tube to nose and secure tube to gown w/safety pin & rubber band •Instill bolus of air (10-30 ml) into stomach while listening with stethoscope to hear if tube is positioned correctly in stomach. •Aspirate gastric contents to check placement and replace contents. |
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How is placement of a nasogastric tube verified?
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•Aspirate stomach contents, which should be acidic. (Most reliable method)
•Place stethoscope over client’s stomach and inject 10-30 ml of air into the tube while listening for a whooshing sound. |
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What is the purpose of assessing gastric residuals?
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To be certain the tube is in the stomach and not the lungs
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What is the purpose of the chambers of a chest tube?
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•COLLECTION CHAMBER – fluid and air comes from chest, drainage
•WATER SEAL CHAMBER – one-way valve – air bubbles up the H2O but no air can re-enter •SUCTION CONTROL – water level controls amount of suction, not wall suction |
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How should the water seal chamber tidal with respirations
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NORMAL is it RISES WITH INHALATION, FALLS WITH EXPIRATION (opposite of mechanical ventilation)
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What indicates an air leak in a chest tube?
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continuous bubbling
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What does an absence of tidaling in a chest tube indicate
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Either there is a kink in the tube, a clot in the tube, or the patient is cured.
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What nursing care is involved with the patient during insertion, maintenance, and removal of a chest tube? Breathing?
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•KEEP TUBING AS STRAIGHT AS POSSIBLE & BELOW PATIENT’S CHEST – don’t permit patient to lie on it, higher than chest=back flow of old drainage
•TAPE OR SECURE ALL CONNECTIONS •MAINTAIN WATER LEVELS – sterile water •ASSESS, MEASURE, AND RECORD DRAINAGE – Q8hrs •CHECK FOR INTERMITTENT BUBBLING (TIDALING) IN THE WATER SEAL •MAINTAIN GENTLE BUBBLING IN SUCTION CHAMBER i.HIGHER FLUID LEVEL = HIGHER SUCTION ii.EXCESSIVE SUCTION DAMAGES TISSUE PLACE 2 RUBBER SHOD HEMOSTATS at bedside AIR LEAK – clamp away from pt until bubbling stops PLACE VASELINE GAUZE AT BEDSIDE – occlusive dressing Removal – have patient hold breath, exhale or valsalva Cough and deep breathe – expansion No routine milking/stripping – pressure problems |
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What nursing care is performed for a patient with a nephrostomy?
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Don’t let tubing get kinked, laid upon, or clamped
Irrigate only if ordered, using aseptic technique – approximately 5 ml |
