MIDTERMSKILLS

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NUTRITION STATUS

Assessment:

 Height (ht)
 Weight (wt) the best indicator for nutritional status of an individual.
 Skin folds (fat folds)
 BMI (Basal Metabolic Index) = wt in kg/ (ht in meter) ₂
o Below 18.5 underweight
o 18.5 – 24.9 normal
o 25.0 – 29.9 overweight/mild obesity
o 30.0 – 39.9 moderate obesity

Clients with Problems in Nutrition

Nursing Diagnosis: a clinical act of identifying problems. A statement of client’s potential/actual


problem.

Purpose: to identify the client’s health care needs and to prepare diagnostic statements. Uses PRS
format.

 P – problem
 R – related to factors
 S – signs and symptoms

Nursing Diagnosis:

Altered nutrition:

 Less than body requirements


 More than body requirements
 Potential for more than body requirements

Altered elimination:

 Diarrhea
 Constipation

Common Problem in Nutrition

1. Anorexia is loss of appetite to eat.


2. Nausea and vomiting
 Ice chips, hot lemon tea, crackers, replace fluid loss.
3. Malnutrition
4. Obesity – 20% greater than ideal body weight
5. Overweight – 10% greater than IBW
How to Stimulate Appetite

 Serve food in pleasant and attractive to client’s eyes


 Place patient in a comfortable position
 Good hygiene
 Promote comfort
 Assist weak patient in feeding
 Engage pleasant conversation

Dehydration

 Thirst – first sign


 Dry mouth/mucous membrane
 Fever, tachycardia, low BP
 Weight loss
 Oliguria
 Poor skin turgor
 Altered LOC (level of consciousness)

Special Diets

 Clear liquid
o Water
o Bouillon
o Clear broth
o Gelatin
o Popsicles
o Coffee/tea
o Soda
o Hard candy
 Full liquid
o Plain rice cream
o Sherbet
 Milk
 Pudding/custard
o Strained soups
 Strained vegetable juice
 Soft – includes soft foods and those with reduced fiber content which require less energy for
digestion
o Chopped or pureed foods
 DAT (Diet as Tolerated) – includes those foods which the client can tolerate after surgery or after
GI distress.
Alternative Feeding Methods

 Oral Gastric Tube – may be used for feedings, medication administration or removal of contents
from the stomach via aspiration, suction, or gravity drainage. It may also be used to help remove
air from your baby’s stomach.
 Nasogastric Feeding – commonly used in Levine Tube French 14-16.
Purposes:
1. To provide feeding – “gastric gavage”
2. To irrigate stomach – “gastric lavage”
3. For decompression – drainage or gastric content
4. To administer medications
5. To administer supplemental fluids.

NGT SIZES and COLORS

Size of NG tube
Feeding Decompression
Neonates 6fr 8fr
Infants to 5 8fr 8-10fr
years
Over 5 years 8-10fr 10-14fr

Equipment needed

Tube – (usually #12, #14, #16 or #18 French for a normal adult.

TYPES OF NGT

 Salem (Double Lumen) pump


o Most common nasogastric tube
o Used for irrigation of stomach and tube feedings
o Sizes 14-18 French
o 120 cm long
o If suction is needed, connect the larger bore to suction
o Blue vent is always open to air for continuous atmospheric irrigation
o Prevent reflux by having the blue vent port above the patient’s waist.
 Single Lumen Tubes
o Levin
 Sizes 14-18 French and 125cm long
 Used for stomach decompressing, withdrawing specimens, washing the stomach free
of toxic substances, and irrigating the stomach and treat upper GI bleeds.
 Can be used to administer meds and/or feedings
 Flocare
 Silicon
 Dual-Purpose Tubes
o Moss Mark IV, Dobbhoff Nasojejunal
 Inserted nasally and ends in the duodenum or jejunum
 Gastric decompression port connects to suction
 Use the smaller, more distal port for feedings
 Reduces reflux through removing excess feedings
 3rd port is a retention balloon
 Double-Lumen Nasointestional Tube
o Miller-Abott tube
 Rubber balloon tip that should not be inflated until passed through the pylorus
 Peristalsis moves balloon along
 Second port is for suction for sampling
 Label the ports to alleviate confusion
 Tubes for Upper GI Bleeding for Varices
o Sengs taken-Blakemore
 Two lumens inflate the gastric and esophageal balloons
 3rd lumen reserved for gastric suction or drainage
 Can be inserted orally or nasally
 Compresses esophageal varices or reduce gastrointestinal hemorrhage
 Percutaneous Endoscopic Gastronomy (PEG) Tube
o Procedure for placing a feeding tube directly into the stomach through a small incision
in the abdominal wall
o Peg tubes can be temporary or permanent
o Peg tube care should be completed every 8 hours with a part hydrogen peroxide part
sterile water, the place a drainage sponge around port.
 J – tube
o Placed in the jejunum
o Last >= 30 days
o Decreases risk for reflux
o Decreases risks for complication in comparison to Peg tube
o Can be a combo of J/G tube
Points to Remember

1. Fowler’s position and hyperextended client’s head.


2. Measure the NGT from the tip of the nose to ear lobe and to the xyphoid process.
3. Place towel on client’s chest
4. Check patency

Techniques:
a. Introduce air 5-20ml and auscultate at the epigastric area and listen to gurgling or
whooshing sound.
b. Aspirate gastric content, which is yellow or greenish color.
c. Immerse tip of the tube in water, no bubbles should be produced.
d. pH test - This method aspires the NG tube and checks the content by using pH paper.
e. Chest Xray - This method offers one of the best ways to check the placement of the NG
tube.
5. Assess residual feeding contents. To check absorption of the last feeding. If ≥ 50ml verify if the
feeding will be given.
6. Introduce feeding slowly. To prevent crampy pain or vomiting.
7. Maintain 12 inches above tube’s point of insertion.
8. Instill 60ml of water into the NGT after feeding. To clean the lumen of the tube.
9. Clamp the NGT before all the water is instilled. To prevent entry of air into the stomach.
10. Maintain client on fowler’s position for at least 30 mins. To prevent potential aspiration.
11. After care equipment then, document observation.

Complication from Improper NGT Placement

 Pneumothorax
 Pulmonary hemorrhage
 Pleural effusion
 Trauma injuries
 Abscess formation
 Nosebleeds
 Asphyxia
 Secondary infection
 Pneumonitis

Common Problems in Tube Feeding

 Vomiting
 Aspiration
 Diarrhea – due to lactose intolerance
 Constipation
 Hyperglycemia
 Abdominal distention
Bowel Elimination

 Defecation is an expulsion of feces from the rectum. It has an involuntary phase when feces
is in the rectum. It becomes involuntary when it reaches to anal sphincter and must relax for
evacuate of the rectum, facilitates by increase abdominal pressure “Valsalva maneuver”.

Characteristics of Stool

 Color: yellow or golden brown


 Odor: aromatic
 Amount: depends on the bulk of food intake approx. 150 to 300 g per day
 Consistency: soft, formed
 Shape: cylindrical
 Frequency: 1-2 per day to every 2-3 days

Abnormal Characteristics

1. Alcoholic stool: gray, pale sue to biliary obstruction


2. Hematochezia: passage of bright red stool due to GI bleeding
3. Melena: passage of black tarry stool due to upper GI bleeding
4. Steatorrhea: greasy, bulky, foul-smelling stool due to presence of undigested fats like in
hepatobiliary-pancreatic obstructions.

Common Fecal Elimination Problem

 Constipation
 Fecal impaction – hardened stool
 Diarrhea
 Flatulence – presence of excessive gas
 Fecal incontinence – involuntary elimination of bowel contents assoc. with emotional
impairments, mental neurologic.

Diarrhea

 Refers to frequent evacuation of watery stools for 3-5 time or more. It is associated with
increased gastric motility.

How to control/stop diarrhea?

1. Replace fluid loss


2. Provide good perineal care. Stool is highly acid it causes irritation in perineal area.
3. Promote rest
4. Diet – low fiber, small amount of bland foods. BRAT (Banana, Rice Am, Apple, Toast)
5. Avoid excessive hot and cold fluids
6. Potassium rich foods and fluids – banana, Gatorade
Urinary Bladder Elimination

Urinary Bladder

 serves as reservoir for urine. It can hold an approx. 1, 000 ml or urine.

Micturition

 it is the act of expelling urine from the bladder also called voiding or urination.

Characteristics:
 color: amber/straw
 odor: aromatic
 transparency: clear
 pH: slightly acidic
Problems in Urinary Elimination

A. Altered urine composition


Hematuria -RBC
Infection
Pyuria – pus
Glycosuria – glucose
Ketonuria – ketones
B. Altered urine production
Polyuria – excessive amount ≥ 100ml/hr or 2500ml/day
Oliguria – decreased amount ≤ 30ml/hr or ≤ 500ml/24hr
Anuria – absence of urine 0-10ml/hr
C. Altered Urinary frequency
Frequency – voiding at frequent intervals
Nocturia – increased frequency at night
Dysuria – painful urination
Urinary incontinence – can be stress incontinence, a continuous and unpredictable loss of urine
less than 50 ml due to coughing, sneezing.
Retention – inability of the bladder to empty. 240-250ml of urine in the bladder triggers by
micturition.
Hand Hygiene

Types of Hand Hygiene:

1. Handwashing with soap and water – 40-60 secs.


Used when hands are visible soiled.
2. Alcohol based hand rub – 20-30 sec. Most effective,
it kills viruses and bacteria.

5 moments of Hand hygiene

1. Before touching a patient


2. Before clean/aseptic procedures
3. After body fluid exposure/risk
4. After touching a patient
5. After touching patient surroundings.

Personal Productive Equipment

- Is an equipment that will protect the user against


health or safety risks at work. It can include items
such as safety helmets, gloves, eye protection, high-
visibility clothing, safety footwear and safety
harnesses. It also includes Respiratory Protective
Equipment (RPE).

PPE DONNING (PUTTING ON)

1. Identify and gather the proper PPE to don. Ensure choice of gown size is correct (based on
training).
2. Perform hand hygiene using hand sanitizer/hand washing.
3. Put on isolation gown. Tie all of the ties on the gown. Assistance may be needed by other
healthcare personnel.
4. Put on N95 filtering facepiece respirator or higher (use a facemask is a respirator is not
available). If the respirator has a nosepiece, it should be fitted to the nose with both hands, not
bent or tented. Do not pinch the nosepiece with one hand. Respirator/facemask should be
extended under chin. Both your mouth and nose should be protected. Do not ware
respirator/facemask under your chin or store in scrubs pocket between patients*
Respirator: respirator straps should be placed on crown of head (top strap) and base of
neck (bottom strap). Perform a user seal check each time you put in the respirator.
Facemask: mask ties should be secured on crown of the head (top tie) and base of neck
(bottom tie). If mask has loops, hook them appropriately around your ears.
5. Put on face shield or goggles. When wearing an N95 respirator or half facepiece elastomeric
respirator, select the proper eye protection to ensure that the respirator does not interfere with
the correct positioning of the eye protection, and the eye protection does not affect the fit or
seal of the respirator. Face shields provide full face coverage. Goggles also provide excellent
protection for eyes, but fogging is common.
6. Put on gloves. Gloves should cover the cuff (wrist) of gown. Healthcare personnel may now
enter patient room.

PPE DOFFING (REMOVING)

1. Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves
can be removed using more than one technique (e.g., glove-in-glove or bird beak).
2. Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the strap and
pulling upwards and away from head. Do not touch the front of face shield or goggles.
3. Healthcare personnel may now exit patient room.
4. Perform hand hygiene.
5. Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than
untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the shoulders and
carefully pull gown down and away from the body. Rolling the gown down is an acceptable
approach. Dispose in trash receptacle. *
6. Remove and discard respirator (or facemask if used instead of respirator). Do not touch the
front of the respirator or facemask.*
Respirator: Remove the bottom strap by touching only the strap and bring it carefully
over the head. Grasp the top strap and bring it carefully over the head, and then pull the
respirator away from the face without touching the front of the respirator.
Facemask: Carefully untie (or unhook from the ears) and pull away from face without
touching the front.
7. Perform hand hygiene after removing the respirator/facemask and before putting it on again if
your workplace is practicing reuse.*

Standard Precautions

- used in the care of all hospitalized individuals regardless of their diagnosis or possible infection
status. They are used in any situations involving blood, all body fluids, excretions, and secretions
except sweat (whether or not blood is present or visible), nonintact skin, and mucous
membranes.
- SP include (a) hand hygiene; (b) use of personal protective equipment (PPE), which includes
gloves, gowns, eyewear, and masks; (c) safe injection practices; (d) safe handling of potentially
contaminated equipment or surfaces in the client environment; and (e) respiratory
hygiene/cough etiquette (sleeve sneeze).

Isolated Precautions

- create barriers between people and germs. These types of precautions help prevent the spread
of infection in the hospital. Anybody who visits a hospital patient who has an isolation sign
outside their door should stop at the nurses' station before entering the patient's room.
Transmission-Based Precautions

- precautions are used in addition to standard precautions for clients with known or suspected
infections that are spread in one of three ways: by airborne or droplet transmission, or by
contact
- designed for all clients in hospital reduce risk of transmission of microorganisms from
recognized and unrecognized sources.
- These precautions apply to (a) blood; (b) all body fluids, excretions, and secretions except sweat;
(c) nonintact (broken) skin; and (d) mucous membranes

Contact Precautions

1. Place client in private room.


2. If a private room is not available, place client with another client who is infected with the same
microorganism.
3. Wear gloves as described in standard precautions.
a. Change gloves after contact with infectious material.
b. Remove gloves before leaving client’s room.
c. Cleanse hands immediately after removing gloves. Use an antimicrobial agent. Note: If
the client is infected with C. difficile, do not use an alcohol-based hand rub because it is
not effective on these spores. Use soap and water.
d. After hand hygiene, do not touch possibly contaminated surfaces or items in the room.
4. Wear a gown (see standard precautions) when entering a room if there is a possibility of contact
with infected surfaces or items, or if the client is incontinent, or has diarrhea, a colostomy, or
wound drainage not contained by a dressing.
a. Remove gown in the client’s room.
b. Make sure uniform does not contact possible contaminated surfaces.
6. Limit movement of client outside the room.
7. Dedicate the use of noncritical client care equipment to a single client or to clients with the
same infecting microorganisms

Transmission-Based Precautions

1. Contact Precautions
Everyone must: clean hand when entering and leaving room. Gown and glove at door.
Doctor and Staff Must: use patient-dedicated or disposable equipment. Clean and disinfect
shared equipment.
Sample disease on Contact Precaution:
 MRSA (mask if respiratory infection)
 VRE
 Adenovirus
 Diarrhea
 C. difficile
 Rotavirus
 E coli 0157
 Enterovirus
 Salmonella
 Shigella
 Hepatitis A
 Herpes Zoster (shingles localized)
 Herpes simplex
 Parainfluenza (mask if coughing)
 RSV (mask if productive cough)
 Lice
 Scabies
 Chicken pox (symptomatic, until all lesions crusted and dried)
2. Droplet Precaution
Everyone must: clean hands when entering and leaving room. Wear mask.
Doctors and staff must: wear eye protection with respiratory symptoms and standard
precautions if contact with secretions likely.
Sample diseases on Droplet Precautions:
 Pertussis
 Influenza A or B
 MRSA (respiratory infection)
 Neissera meningitides (suspected or confirmed)
 Coxsackie
 Bacterial meningitis (for 24 hours after effective antibiotic therapy)
 RSV (droplet and contact)
 Mumps
 Rubella
Droplet Precautions
1. Place client in private room.
2. If a private room is not available, place client with another client who is infected with the same
microorganism.
3. Wear a mask if working within 1 m (3 ft) of the client.
4. Limit movement of client outside the room to essential purposes. Place a surgical mask on the
client while outside the room.

3. Airborne Precaution
Everyone must: clean their hands, including before entering and when leaving the room. Put on
a fit-tested N95 or higher-level respirator before room entry. Remove respirator after exiting the
room and closing the door. Door to room must remain closed.
Sample disease on airborne precautions:
 Chicken pox
 Disseminated herpes zoster (shingles)
 Measles
N95 mask:
 Tuberculosis
 SARS
 Avian influenza

Reverse isolation/Protective Isolation


 refers to the practice of healthcare workers and visitors wearing barriers (i.e.,, gown, gloves,
mask, etc.) routinely upon entry to the client room, for the purpose of preventing client
exposure to external microbes.
 used in immunocompromised patient
 what you need:
1. Private room-closed at all times
2. Disposable gown, mask, gloves if with direct contact
3. Hand hygiene
4. No plants and flowers in the room
NASOGASTRIC TUBE INSERTION (NGT)
Definition:
An alternative feeding method that ensures adequate nutrition which is provided when the client
cannot ingest foods or the upper GI tract is impaired and the transport of food to the small intestine is
interrupted.
Purposes:
 To administer tube feedings and medications to clients unable to eat by mouth or swallow a
sufficient diet without aspirating food or fluids into the lungs
 To establish a means for suctioning stomach contents to prevent gastric distention, nausea, and
vomiting
 To remove stomach contents for laboratory analysis
 To lavage (wash) the stomach in case of poisoning or overdose of medications

Assessment:
1. Check for history of nasal surgery or deviated septum.
2. Assess patency of nares.
3. Determine presence of gag reflex.
4. Assess mental status or ability to participate in the procedure
Equipment:
1. Large- or small-bore tube (nonlatex preferred) / NG Tube
2. Non-allergenic adhesive tape, 2.5 cm (1 in.) wide
3. Clean gloves
4. Water-soluble lubricant
5. Facial tissues
6. 20- to 50-mL catheter-tip syringe / Asepto Syringe
7. Basin
8. Stethoscope
STEPS RATIONALE
Assist the client to a High-Fowler’s position if his It is often easier to swallow in this position and
or her health condition permits, and support the gravity helps the passage of the tube.
head on a pillow.
Introduce yourself, verify client’s identity and To gain client’s cooperation.
explain to the client what you are going to do.
Wash hands and provide privacy.
Determine how far to insert the tube. This length approximates the distance from the
 Use the tube to mark off the distance from nares to the stomach.
the tip of the client’s nose to the tip of the
earlobe and then from the xiphoid. This
distance varies among individuals.
 Mark this length with adhesive tape if the
tube does not have markings.
Insert the tube.
• Lubricate the tip of the tube well with water- A water-soluble lubricant dissolve if the tube
soluble lubricant or water to ease insertion. accidentally enters the lungs. An oil-based
lubricant, such as petroleum jelly, will not
dissolve and could cause respiratory
complications if it enters the lungs.

Hyperextension of the neck reduces the


• Insert the tube, with its natural curve curvature of the nasopharyngeal junction.
downward, into the selected nostril. Ask the
client to hyperextend the neck, and gently
advance the tube toward the nasopharynx.
Tears are a natural body response. Provide the
• Direct the tube along the floor of the nostril client with tissues as needed.
and toward the midline.
Rationale: Directing the tube along the floor
avoids the projections (turbinates) along the
lateral wall.

The tube should never be forced against


• Slight pressure and a twisting motion are resistance because of the danger of injury.
sometimes required to pass the tube into the
nasopharynx, and some client’s eyes may water
at this point.

Tilting the head forward facilitates passage of the


• If the tube meets resistance, withdraw it, tube into the posterior pharynx and esophagus
relubricate it, and insert it in the other nostril. rather than into the larynx; swallowing moves the
• Once the tube reaches the oropharynx epiglottis over the opening to the larynx.
(throat), the client will feel the tube in the throat
and may gag and retch. Ask the client to tilt the
head forward, and encourage the client to drink
and swallow. If the client gags, stop passing the
tube momentarily. Have the client rest, take a
few breaths, and take sips of water to calm the
gag reflex.

The tube may be coiled in the throat. If so,


• In cooperation with the client, pass the tube 5 withdraw it until it is straight, and try again to
to 10 cm (2 to 4 in.) with each swallow, until the insert it.
indicated length is inserted.

• If the client continues to gag and the tube does To determine if the tube is really in client’s
not advance with each swallow, withdraw it stomach and not.
slightly, and inspect the throat by looking through
the mouth.

•Ascertain correct placement of the tube.


Once correct position has been determined,
attach the tube to a suction source or feeding
apparatus as ordered, or clamp the end of the
tubing.
Secure the tube to the client’s gown. To prevent it from dangling and pulling.
Perform after care and wash hands.
Document procedure and client’s response to
include color and amount o gastric content.
NASOGASTRIC TUBE (NGT) FEEDING

PURPOSES:

 To restore or maintain nutritional status


 To administer medications

ASSESSMENT:

 For any clinical signs of malnutrition or dehydration.


 Tolerance to previous feedings.
 For allergies to any food in the feeding. If the client is lactose intolerant, check the tube feeding
formula. Notify the primary care provider if any incompatibilities exist. > For the presence of
bowel sounds.
 For any problems that suggest lack of tolerance of previous feedings (e.g., delayed gastric
emptying, abdominal distention, diarrhea, cramping, or constipation).

EQUIPMENT:

1. Correct type and amount of feeding


2. Asepto syringe
3. Emesis basin
4. Clean gloves
5. Water

STEPS RATIONALE
Assist the client to a Fowler’s position (at least These positions enhance the gravitational flow of
30° elevation) in bed or a sitting position in a the solution and prevent aspiration of fluid into
chair, the normal position for eating. If a sitting the lungs.
position is contraindicated, a slightly elevated
right sidelying position is acceptable.
Introduce yourself, verify client’s identity and To gain client’s cooperation.
explain to the client what you are going to do.
Wash hands For infection control.
Provide privacy. This procedure may be embarrassing to some
clients.
Remove the plunger from the syringe and Pinching or clamping the tube prevents excess air
connect the syringe to a pinched or clamped from entering the stomach and causing
gastric tube distention.
Assess tube placement. Determines location of the tube.
 Testing the pH
 Checking for residual contents
 Auscultating for gurgling sounds by injecting air.
Administer the feeding. Quickly administered feedings can cause flatus,
While clamping the NG tube, pour the feeding cramps, and/or vomiting.
unto the Asepto syringe, release clamping, and
permit the feeding to flow slowly. If the client
experiences discomfort, pinch or clamp the
tubing to stop the flow.
Finish the feeding by adding water to the NG Flushes any residual feeding that may obstruct
tube. tube.
Ask the client to remain sitting upright in Fowler’s These positions facilitate digestion and
position or in a slightly elevated right lateral movement of the feeding from the stomach
position for at least 30 minutes. along the alimentary tract, and prevent the
potential aspiration of the feeding into the lungs.
Perform after care and monitor the client for
possible problems.
Document all relevant information
NASOGASTRIC TUBE(NGT) REMOVAL

ASSESSMENT:

 For the presence of bowel sounds


 For the absence of nausea or vomiting when tube is clamped

EQUIPMENT:

 Tissues
 Clean gloves
 Moisture-proof trash bag

STEPS RATIONALE
Check doctor’s order for confirmation of removal
of NGT.
Assist the client to a sitting position, if possible.
Introduce yourself, verify client’s identity and To gain client’s cooperation/
explain to the client what you are going to do.
Wash hands. For infection control.
Provide privacy. This procedure may be embarrassing to some
clients.
Don clean gloves For infection control.
Remove the adhesive tape securing the tube to
the nose.
Pinch the tube with the gloved hand. Smoothly, Pinching the tube prevents any contents inside
withdraw the tube. the tube from draining into the client’s throat.
Place the tube in the trash bag. Placing the tube immediately into the bag
prevents the transference of microorganisms
from the tube to other articles or people.
Ensure client comfort. Excessive secretions may have accumulated in
Provide mouth care if desired. the nasal passages.
Perform after care and monitor the client for
possible problems.
Document all relevant information. Record the removal of the tube, the amount and
appearance of any drainage.
OROGASTRIC TUBE (OGT) FEEDING

DEFINITION:

 A thin soft tube is passed through a child’s mouth, through the oropharynx, through the
esophagus and into the stomach

PURPOSES:

 To restore or maintain nutritional status


 To administer medications

ASSESSMENT:

 Correct placement of the tube.

EQUIPMENT:

1. Correct type and amount of feeding


2. Syringe (Barrel)
3. Emesis basin
4. Clean gloves
5. Water

STEPS RATIONALE
Place the infant/child in a upright position. This position decreases the risk of aspiration.
Remove the plunger from the syringe and place
the tip of the syringe into the enteral tube
connector at the end of the enteral tube.
Holding the syringe and enteral tube straight,
pour the prescribed amount of feeding into the
syringe.
Let it flow slowly through tube.
Pour the prescribed amount of water into the Flushing prevents blockage of tube.
syringe and allow to flow through to flush the
feeding tube.
Replace the cover of the tube. Flushing prevents blockage of the tube.
Replace cover of the tube. To ensure that no air can pass through the tube.
Maintain infant/child’s upright position for 30 To avoid regurgitation.
minutes.
Perform after care.
Document all pertinent observations.
ADMINISTERING A GASTROSTOMY OR JEJUNOSTOMY TUBE FEEDING

DEFINITION:
A percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ) is created
by using an endoscope to visualize the inside of the stomach, making a puncture through the skin and
subcutaneous tissues of the abdomen into the stomach, and inserting the PEG or PEJ catheter through
the puncture. The surgical opening is sutured tightly around the tube or catheter to prevent leakage.
PURPOSES:
 To restore or maintain nutritional status.
ASSESSMENT:
1. For any clinical signs of malnutrition or dehydration.
2. For allergies to any food in the feeding. If the client is lactose intolerant, check the tube feeding
formula. Notify the primary care provider if any incompatibilities exist.
3. For the presence of bowel sounds.
4. For any problems that suggest lack of tolerance of previous feedings (e.g., delayed gastric
emptying, abdominal distention, diarrhea, cramping, or constipation).
EQUIPMENT:
1. Correct type and amount of feeding
2. Asepto syringe
3. Emesis basin
4. Clean gloves
5. Water

STEPS RATIONALE
Introduce yourself, verify client’s identity and
explain to the client what you are going to do.
Wash hands and provide privacy. To gain client’s cooperation.
Don gloves For infection control.
Administer the feeding.
• Hold the barrel of the syringe 7 to 15 cm (3 to 6
in.) above
• Slowly pour the solution into the syringe and Quickly administered feedings can cause flatus,
allow it to flow through the tube by gravity. cramps, and/or vomiting.
Just before the syringe is empty, add 30 mL of Water flushes the tube and preserves its patency.
water.
Remove the syringe, and then clamp or plug the To prevent blockage.
tube.
Remove and discard gloves.
Perform hand hygiene For infection control.
Ensure client comfort and safety. This prevents the risks of aspiration.
Position the client in semi-sitting or sitting
position.
Perform aftercare and wash hands.
Document all pertinent observations.
NASOGASTRIC TUBE INSERTION AND FEEDING

Introduction:
 Nasogastric tube feeding is common practice and many tubes are inserted daily without incident.
However, there is a small risk that the tube can become misplaced into the lungs during insertion,
or move out of the stomach at a later stage.
 Auscultation must not be used to check correct nasogastric tube (NGT) placement as studies have
shown this method to be inaccurate. NG tubes should be aspirated and the tube position confirmed
using pH indicator strips that are CE marked and intended for use on human gastric aspirate.
DEFINITION OF NGT INSERTION
 Naso-gastric a method of introducing a tube through nose into stomach for therapeutic or
diagnostic purpose.
Naso-gastric feeding tube:
 Defined as between a between a 6 – 8 French gauge. The length of the tube is measured in cm
starting at the distal tip (stomach end = “0” cm). The tube is made of silicone or polyurethane
which is passed through the nostril via the naso-pharynx into the esophagus, then stomach.
 Nasogastric tubes used for the purpose of feeding must be radio-opaque throughout their
length and have

PURPOSE OF NGT
INSERTION:

 To feed with fluids when oral intake is not possible


 To dilute and remove consumed position.
 To instill ice cold solution to control gastric bleeding.
 To prevent stress on operated site by decompressing
 To relieve vomiting and distention
 To collect gastric juice for diagnostic purposes.

DUTIES AND RESPONSIBILITIES:

Medical Staff:

 The decision to commence artificial nutrition via a naso-gastric tube is a medical decision to be
made in conjunction with the patient, the patients’ family and members of the MDT.
 Before a decision is made to insert a naso-gastric tube, an assessment is undertaken to identify
if nasogastric feeding is appropriate for the patient, and the rationale for any decisions is
recorded in the patients’ medical notes.

Radiology Department:

 Radiographers: are responsible for ensuring that the nasogastric tube can be clearly seen on the
x-ray to be used to confirm tube position.

DUTIES AND RESPONSIBILITIES

Healthcare Professionals (including Registered Nurses)


 Healthcare Professionals are responsible for establishing the gastric placement of NGTs prior to
their use and to document this using the NG checking chart.
 It is the responsibility of the Healthcare Professional to develop and maintain their own level of
care.
Clinical Nutrition Nurse Specialists (CNNS):
 CNNS team is responsible for providing training and education to PHT staff on the insertion and
management of nasogastric feeding tubes.
 Clinical Nutrition Nurse Specialists in conjunction with Modern Matrons, Ward Managers, and
Practice development Nurses and Clinical Educators are responsible for the management and
Implementation of this policy.

SELECTION OF NASOGASTRIC TUBE:


 Select the feeding tubes based on the tube’s composition, intended use, estimated length of
time required, cost effectiveness and tube features.
 Soft, flexible, small diameter tube (8 Fr to 12 Fr) is recommended for nasogastric feeding.
 Use Polyurethane or silicone tubes for anticipated long-term feeding rather than
polyvinylchloride tubes.
 Polyvinylchloride (PVC) tubes should be used for a short period of time usually for gastric
drainage, decompression, lavage or diagnostic procedures.
 Smaller size feeding tube improves patient comfort. Common complications associated with the
use of larger and stiffer tubes include nasopharyngeal erosions / necrosis, sinusitis and otitis
media.
 For short-term usage, PVC feeding tubes have adequate efficacy and are more cost effective

EQUIPMENT REQUIRED FOR NGT INSERTION PROCESS:


A tray containing-
 Drainage bag or enteral administration set, if needed
 Non sterile disposable gloves / PPE
 Oral /enteral syringe 20ml or 50ml x 2
 pH indicator strips – non bleeding
 Lubricant (water soluble)
 Safety pin (to attach tube to clothing)
 Vomit bowl
 Tissue & towel / absorbent sheet
 Adhesive tape (Fixomul or similar)

EQUIPMENT REQUIRED FOR NGT INSERTION PROCESS:


 Penlight / torch
 NGT (Consider duration of use & why tube needed e.g. gastric drainage, feeding or medication)
 Glass of water (only if the patient is not Nil by mouth / fasting) & straw.
Additional equipment which may be required:
 Local anesthetic if prescribed on MR810
 Spigot, specimen container and Laboratory request form.

PROCEDURE- NASOGASTIC INSERTION:

 Wash hand thoroughly


 Measure distance of tube from tip of patient’s ear lobe to nose to tip of xiphoid process.
 Mark the distance of the tube
 Lubricate the tube of about 6 to 8 inches with the lubricant using a rag piece or a paper square.
 Hold the tube coiled in the right hand introduces the tip into the left nostril.
 Pass the tube gently but quickly backwards momentary resistance may occur as the tube is
passed into the naso-pharynx.
 When the tube reaches to pharynx the patient may gag. Allow him to rest for a movement.
 Have the patient take the sips of water on command advance the tube 3-4 inches each time
swallows.
 Make sure tube is in stomach.
 Once location of NG tube insured close other end of tube with spigot, secure tube on nose using
adhesive in ‘T’ or butterfly.

NASOGASTRIC TUBE FEEDING (NGT FEEDING)

 Introduction:
 Patients in the hospital, as well as home care settings, often require nutritional supplementation
with enteral feeding.
 Enteral feeding can be administered via nasogastric, nasoduodenal and nasojejunal means. The
focus of this clinical practice guideline is on the nursing management of nasogastric tube
feeding.
 Nasogastric tube feeding may be accompanied by complications.
 Thus, it is important for the practitioner to be aware of how to
DEFINITION:
 Nasogastric tube feeding is defined as the delivery of nutrients from the nasal route into the
stomach via a feeding tube
MANAGEMENT OF NGT FEEDING:

pH TESTING:

 A Combination of aspirate appearance and pH testing can be used to help make correct
predictions about tube placement in the stomach.
 pH value of aspirates from feeding tubes should be used to differentiate between gastric and
respiratory placement.
 The pH values and their corresponding indications and action:

VALUE INDICATIONS ACTION


pH less than 5 Gastric Proceed to feed
pH 5 – 6 Check visual characteristics of If visual characteristics indicate
aspirates. gastric aspirates, proceed to
feed. Otherwise, do check x-ray
to confirm tube placement.
pH more than 6 Intestinal or Respiratory Do check x-ray to confirm tube
placement.

VISUAL CHARACTERISTICS OF FEEDING TUBE ASPIRATES:

 Combination of pH and visual characteristics can be helpful in distinguishing between


respiratory and gastrointestinal tube position.
 pH less than 5 indicates gastric placement, whereas a pH more than 5 indicates intestinal or
respiratory placement.

GASTRIC INTESTINAL RESPIRATORY


May be grassy green with Generally, more transparent Trachea-broncheal secretion
sediment, brown (if blood is than gastric aspirates and may may consist of off-white to tan
present and has been acted on appear bile stained, ranging in sediment.
by gastric acid). color from light to dark yellow
golden yellow or brownish-
May also appear clear and green.
colorless (often with shreds of
off-white to tan mucus or
sediment).

Frequency in Checking Placement


 Mark the intersection where the nasogastric tube enters the nostril, use this marking to check
the tube placement:
 after initial insertion, before each intermittent feeding, and at Every 8-hourly during continuous
feedings.
 If patients complain of discomfort, coughing, retching or
 Vomiting and show sudden signs of respiratory difficulties.
 If the visible part of the tube changes in the
Maintaining Tube Patency:

 Flush feeding tubes with 30 ml of water before and after intermittent feeding, every 4-hourly
during continuous feeding and after checking for gastric residuals. More frequent flushing might
be ordered according to patient’s condition.
 Flush feeding tube before and after administration of each Medicine and after checking for
residual.

FEEDS AND DELIVERY SYSTEM:

 Wash hands before preparing and handling delivery sets.


 Use mask if handler has a cold, sore throat or upper respiratory tract infection.
 Use clean technique when handling the feeding system. Limit the hang time of the formula to:
 4 hours for powdered, reconstituted formula and enteral nutrition formula with additives
 8 hours for sterile, decanted formula in open system
 24–48 hours per manufacturer’s guidelines for closed system
 enteral nutrition formula
 Use pre-prepared feeds for enteral feeding.
 Initiate all formulas at full strength.

FEEDING POSITION:

 The patient should be placed at a semi-recumbent position or elevated to an angle of at least


30o during and after feeding for at least one hour.
 Elevation of the head of bed at least 300 during tube feeding decreases the risk of aspiration of
gastric content.
 Gravity reduces the likelihood of regurgitation of gastric contents from the distended stomach.
There is evidence that a sustained supine position (with the head of the bed flat) increases
gastro esophageal reflux (GER) and the probability for aspiration.

TYPES OF FEEDING:

1. Bolus Feeding:
 The total volume of feeds administered should not exceed 400ml during each bolus feed.
 Both the speed and volume with which formula is delivered has an impact on intragastric
pressure and the probability of gastroesophageal reflux.
 Bolus feeding of more than 400 ml and rapid infusion may result in abdominal distension and
discomfort.
2. Continuous Feeding
 Use feeding pump for administration of continuous feeds.
 Start with an initial slow rate of 10 to 40 ml/hour. Advance to the goal rate by increasing the
rate by 10 to 20 ml/hour every 8-12 hours as tolerated.
 Continuous feeding is recommended for patients who are critically ill, receiving jejunal feedings;
or patients who are unable to tolerate intermittent feedings. Pump-assisted delivery of enteral
feeds is highly recommended for small
Management of Feeding Intolerance

 When patient shows signs of feeding intolerance such as


o nausea, vomiting, abdominal distension and pain:
 Perform a physical examination of the abdomen including
 Assessment for presence of abdominal pain and bowel sounds.
 Feeding should only be stopped abruptly for those patients who demonstrate overt
regurgitation or aspiration.

Monitoring and Management of Gastro-intestinal Tolerance

 Gastric residual volume (GRV) should be checked 4-8 hourly in Continuously fed patients and
before each intermittent feeding.
 GRV greater than 200 ml should prompt careful bedside evaluation and initiation of appropriate
feeding method and feeding volume. GRV reading should be evaluated in conjunction with
physical examination for abdominal distension, absence of bowel sounds, and presence of
nausea and vomiting.
 A trend in GRV may be more important than an isolated high level of GRV.
 There is no significant difference between returning and not returning gastric residuals.

DECLOGGING:

 Use warm water to declogg obstructed feeding tubes. If unsuccessful, pancreatic enzyme with
sodium bicarbonate may be used.
 Warm water is the most effective irrigant in declogging blocked feeding tubes. However, a
solution of digestive enzymes (pancrealipase) mixed with sodium bicarbonate (to activate the
enzyme) has been shown to be fairly effective in dissolving formula occlusions.

ASSESSMENT / MONITORING OF DIARRHEA:

 Patients on antibiotics should be monitored for symptoms of Diarrhea.


 Characteristics of the formula composition, method of administration and contamination of
formulas can cause diarrhea in tube fed patients. The antibiotics reduce bacteria within the
colon that is necessary for the digestion of fiber and subsequent release of short chain fatty
acids (SCFA)

RECAPTUALIZATION:

Nasogastric tube feeding may be accompanied by complications. Thus, it is important for the
practitioner to be aware of how to prevent these complications so that nasogastric tube feeding can be
administered successfully and safely.
CAPILLARY BLOOD GLUCOSE TESTING

Capillary Blood Glucose

- Capillary blood glucose (CBG) testing was developed to replace home urine glucose testing by
patients or by the staff in physician offices. CBG testing can also be applied in the hospital
laboratory as a cost-effective method to rapidly test blood glucose levels.

Purpose:
 convenient way of monitoring blood glucose patterns and can be a useful aid in guiding
treatment changes in patients with type 1 and type 2 diabetes especially during periods of
instability, for example, illness or frequent hypo glycaemia.
 A test to determine blood glucose level
Objectives:

1. To determine or monitor blood glucose levels of clients at risk for hyperglycemia or


hypoglycemia. A test to determine blood glucose level
2. To promote blood glucose regulation by the client
3. To evaluate the effectiveness of insulin administration

Materials:

1. Glucometer
2. Lancet holder
3. Test strips
4. Gloves
5. Alcohol
6. Cotton balls
7. Lancets

HGT USING HEMO GLUCO TEST

STEPS RATIONALE
1. Test the machine’s calibration with a Varies the machine accuracy.
control strip or solution supplied by the
manufacturers. If not have been done since
midnight
2. Arrange care so that the test is Ensure consistency in obtaining data and
performed approximately 30 minutes before a facilitates detection of trends.
meal and at bed time.
3. Collect the necessary equipment and Promote efficient time management.
Supplies.
4. Turn on the machine, observe the last Prepare the machine for testing the blood
blood glucose reading current test strip sample. The machine retains the last glucose
code and the message “insert strip”
measurement in its memory
5. Place the matched end of one strip into Locates the strip in position for the action
the holder with one test strip. of the blood.
6. Assemble the lancet within the spring Loads hold the lancet in place and prepare
loaded lancet holder. the lancet for rapid trust to the skin.
7. Don clean gloves after washing hands or Provides a barrier to blood exposure.
performing hand antisepsis with alcohol rub.
8. Select a non-traumatized side of a Avoid puncturing an area with sensitive nerve
clients’ finger or thumb; avoid the central Endings.
pads
9. Place the injector, if used, against the The lancet is designed to pierce the skin at
site, and release the needle, thus permitting a specific depth when it is in a
it to pierce the skin. Make sure the lancet is perpendicular position relative to the skin.
perpendicular to the site.
9.Prick the site with a lancet or needle,
using a darting motion.
Gently squeeze (but do not touch) the puncture
site until a drop of blood forms. The size of the
drop of blood can vary depending on the meter.
Some meters require as little as 0.3 mL of blood
to accurately test blood sugar.
Hold the reagent strip under the puncture site Smearing will cause an inaccurate reading.
until adequate blood covers the indicator square.
The pad will absorb the blood and a chemical
reaction will occur.
Do not smear
Ask the client to apply pressure to the skin Pressure will assist hemostasis.
puncture site with a 2×2 gauze.
10. Expose the blood to the test strip for the
period and the manner specified by the
manufacturer. As soon as the blood is placed on
the test strip:
Follow the manufacturer’s recommendations on The blood must remain in contact with the test
the glucose meter and monitor for the amount of strip for a prescribed time to obtain accurate
time indicated by the manufacturer results.
1. Measure the blood glucose.

Place the strip into the meter according to the


manufacturer’s instructions. Refer to the specific
manufacturer’s recommendations for the specific
procedure.

After the designated time, most glucose meters


will display the glucose reading automatically.
Correct timing ensures accurate results.
Turn off the meter and discard the test strip and
2×2 gauze in a biohazard container. Discard the
lancet into a sharp container.

Remove and discard gloves.

Perform hand hygiene.


12. Document the method of testing and results
on the client’s record. If appropriate, record the
client’s understanding and ability to demonstrate
the technique. The client’s record may also
include a flow sheet on which capillary blood
glucose results and the amount, type, route, and
time of insulin administration are recorded.
Always check if a diabetic flow sheet is being
used for the client.

Documentation:

1. Date and time


2. Pertinent pre assessment data, if any
3. Results obtain using the glucometer
4. Test data are recorded on a diabetic flow sheet
5. Treatment provided based on the abnormal test results
BASIC LIFE SUPPORT

 Generally, refers to the type of care that first-responders, healthcare providers and public safety
professionals provide to anyone who is experiencing cardiac arrest, respiratory distress or an
obstructed airway, requires knowledge and skills in cardiopulmonary resuscitation (CPR), using
automated axternal defibrillators (AED) and relieving airway obstructions in patients of every age.
(REDCROSS)
 Is a level of medical care which is used for victims of life-threatening illnesses or injuries until they
can be given full medical care by advanced life support providers. It can be provided by trained
medical personnel, such as emergency medical technicians, and by qualified bystanders. (Wikipedia)
 Includes recognition of signs of sudden cardiac arrest SCA) heart attack, stroke, and foreign-body
airway obstruction (FBAO): cardiopulmonary resuscitation (CPR): and defibrillation with an
automated external defibrillator (AED)

CARDIO PULMONARV RESUSCITATION

 CPR means giving rescue breaths followed by a number of chest compressions, and repeating
this cycle continuously until the ambulance arrives.

CPR Is as easy as C-A-B

 Compressions – push hard and fast on the center of the victim’s chest.
 Airway – tilt the victim’s head back, and lift the chin to open the airway.
 Breathing – give mouth-to-mouth rescue breaths.

Before starting CPR

 Ensure your own safety first. then that of the victim (for example, if the victim s lying on a road, take
steps to alert oncoming traffic).
 Gently tap the victim and shout "are you alright?" If the victim can respond and there is no further
danger from their location, leave the victim in the position they are in. If there is no response, shout
for help. Send for help if there is more than one rescuer present.
 Ask that person to dial 911/ depend on your local number for an ambulance cand return to confirm
that the ambulance is on the way. Tell the ambulance dispatcher the location and telephone number
closest to the scene and be prepared to provide other information before hanging up.
 Do not hang up until instructed to do so.
 If alone, the rescuer should assess the victim for unresponsiveness and absence of signs of life before
going for help,
 The victim must be on his/her back on a firm surface
 If the victim is unconscious, breathing and has other signs of life, turn the victim onto his/her side in
the recovery position and ensure the airway is kept open.
PROCEDURE

1. Position the casualty lying on their back. Ensure they are on a firm surface
2. Kneel to one side of the casualty.
3. Locate the notch where the ribs meet the breastbone.
4. Place the middle finger of one hand in the notch and the index finger next to the middle finger
5. Place the heel of the other hand next to the two fingers.
6. Place the other hand on top so the heels of both hands are over the same point on the
breastbone.
7. Interlock the fingers to keep them off the chest.
8. With your elbows straight and locked, and your shoulders over the casualty’s chest, press straight
down using the weight of your body to compress the breastbone 4 - 5cm (the depth of an adult's
thumb). Use a smooth uninterrupted rhythm allowing equal time for compression and relaxation.
9. Give 30 compressions at a rate of 80-100 compressions a minute.
10. Give two slow, full breaths.
11. Reposition hands and administer a further 30 compressions/two breaths
12. Continue the ratio of 30 compressions/two breaths. After completing four cycles of chest
compressions and breaths, administer two further breaths and then check the pulse in the neck.

Recovery position

The recovery position Is designed for unconscious casualties (but do not use if you suspect the casualty
has neck or spinal injuries). It helps to maintain an open airway and allows vomit and other fluid to drain
freely from the mouth. To move a causality lying on their back into the recovery position, follow these
step

1. Kneel beside the causality.


2. With the casualty lying on their back, extend the arm nearest to you above the casualty's head.
3. Bring their other arm across the chest to place the palm on the opposite shoulder.
4. Take the farthest away from you and cross it over the other leg at the ankle
5. Roll the casualty towards you by placing your hand on their hip and your other hand on their
shoulder.
6. The casualty will now be lying on their side, resting on your thighs.
7. Tilt the head to ensure the airway is open.
8. Bend the top leg at a right angle.
9. The casualty will now lie in a stable unsupported position.

A high-quality CPR, Including

a. A compression rate of at least 100/min (a change from "approximately" 100/min)


b. A compression depth of at least 2 inches (5 cm) in adults and a compression depth of at least
one third of the anterior posterior diameter of the chest in infants and children (approximately
1.5 inches 14 cm in infants and 2 inches5 cm] in children).
Advanced Cardiovascular Life Support
refers to a set of clinical guidelines for the urgent and emergent treatment of life-threatening
cardiovascular conditions that will cause or have caused cardiac arrest using advanced medical
procedures, medications, and techniques ACLS algorithms frequently address at least five different
aspects of per-cardiac arrest care:
1. 1 Airway management
2. ventilation
3. CPR compressions (continued from BLS)
4. 4 defibrillations
5. medications

Successful ACLS treatment generally requires a team of trained individuals

AUTOMATED EXTERNAL DEFIBRILLATOR

AED) are portable, life-saving devices designed to treat people experiencing sudden cardiac arrest, a
medical condition in which the heart stops beating suddenly and unexpectedly

COMPONENTS OF AN AED:

1.AED manufacturers build the box-like device differently,


2. Basic AED components:
a. An electrical box
b. Sticky patches with a cord
c. A speaker for voice commands
d. Cleaning wipes (optional)
e. Directions

PORTABLE DEFIBRILLATOR (AED)

3. Several colored buttons

a. On button (power)
b. Shock button (to deliver a shock)
c. Display screen (voice/text commands)

4. Defibrillation is the stopping of the fibrillation of the heart to restore normal contractions, especially
by the use of an electric shock.
Altered Level of Consciousness (LOC)

 Consciousness may be impaired by any disorder that affects the cerebral Hemisphere of the
brain stem. When assessing LoC, make sure that you provide a stimulus that' s strong enough to
get a true picture of the patient s baseline.
 The Glasgow Coma Scale offers an Objective way to assess the patient's LOC. Decerebrate and
decorticate postures are indicators of severe neurologic damage. LOC 1s the most sensitive
indicator of neurologic dysfunction and may be a valuable adjunct to other findings.
- The reliability of the GCS is based on recording the patient 'best" response.
- If the patient does not follow commands or 1s unresponsive to voice, then the nurse proceeds to
increasingly noxious (painful) stimuli to elicit an eye and motor response.
- Typically, the patient’s response to central pain (brain response) 1s assessed first.
- On the basis on this respon.se, peripheral pain may then be assessed.
- Failure to apply painful stimuli appropriately may lead to an incorrect conclusion about the patient
's neurologic status.
- If the patient responds fully to voice or light touch, there is no need to progress to more vigorous or
painful stimuli.

PROCEDURE

1. Start with the least noxious irritation or pressure and proceed to more painful stimulation it the
patient does not respond.
2. Begin each phase of the assessment by speaking in a normal voice.
3. If no response is obtained, use a loud voice. If the patient does not respond, gently shake him or
her.
4. The shaking should be similar to that sed in attempting to wake up a child.
5. 1f that is unsuccessful, apply painful stimuli using one of these methods:

METHODS

 Supraorbital (above eyes) pressure by placing a thumb under the orbital rim in the middle of the
eyebrow and pushing upward. Do not use this technique if the patient has orbital or facial fractures.
 Trapezius muscle squeeze by pinching or squeezing the trapezius muscle located at the angle of the
shoulder and neck muscle.
 Mandibular (jaw) pressure to the jaw by using your index and middle fingers to pinch the 1lower
jaw.
 Sternal (breastbone) rub by making a fist and rubbing/twisting your knuckles against the Sternum

NOTE:

 The tissue in these areas is tender, and bruising is not unusual.


 Therefore, do not use this technique for older adults or for patients who may experience severe
bruising (e.g., recipients of anticoagulant therapy). &Peripheral pain is assessed with pressure at
the base of the nail on one finger and one toe and both on the right and left.
 The patient may respond to painful stimuli in several ways.
NOTE:

 Although the initial response to pain may be abnormal flexion or extension, continued
application of pain for no more than 20 to 30 seconds may demonstrate that he or she can
Localize or Withdraw.
 If the patient does not respond after 20 to 30 seconds, stop applying the painful stimulus.

Nursing Safety Priority

 A decrease of 2 or more points in the Glasgow Coma Scale total is clinically significant and
should be communicated to the health care provide immediately.
 Other findings requiring urgent communication with the health care provider include a new
finding of abnormal flexion Or extension, particularly of the upper extremities (decerebrate or
decorticate posturing) pinpoint, dilated, and nonreactive pupils and sudden or subtle changes in
mental status. Remember, changes in cognition are the earliest signs or changes in neurologic
status.
 Early recognition of neurologic changes and communicating changes to the health care provider
provide the best opportunity to prevent complications and preserve function

Level of Consciousness

- Level of consciousness (LOC) can lie anywhere along a continuum from a state of alertness to
Coma. A fully alert client responds to questions Spontaneously? a comatose client may not
respond to verbal stimuli
- The Glasgow Coma scale was originally developed to predict recovery from a head injury
however, it is used by many professionals to assess LOC. It tests in three major areas: eye
response, motor response, and verbal response. An assessment totaling 15 points indicates the
client is alert and completely oriented. A comatose Client scores 7 or less
NON-SURGICAL MASK AND GOWN TECHNIQUE

PROCEDURE:

A. PUTTING THE MASK & GOWN

1. Assemble equipment.
2. Write name on envelope for which to keep mask.
3. Using both hands, open the mask at the corners taking care not to touch the inside part.
4. Place the mask over the mouth & nose, then the string at the back.
5. Hold gown at shoulder seams, take gown from hook & hold at arm length.
6. Open gown & slipped arms through sleeves. 2
7. Draw the neck of the gown into place, touching only the inner part of the gown.
8. Tie the upper strings at the neck.
9. Draw the left side of the gown across the back & cross right side over it.
10. Draw the belt end & fasten them at the back.

B. REMOVING THE GOWN & MASK:

1. Wash hands with betadine wash & dry them with the towel.
2. Unfasten the string of the gown at the back of the neck and belt.
3. Put one finger inside the sleeve without touching the outer part & place it over the head.
4. With the protected end, pull the other sleeves with the opposite hand.
5. Slip the gown off, turning inside out.
6. Make a pocket at the shoulder seams & hang the gown on the rack.
7. Remove the mask by touching only the ties.
8. Scrub hands, forearms & elbow thoroughly with soap & water for at least 1 minute in
the utility room.

Note:

1. Mask should never be place inside the worker’s pocket or be left hanging around the neck.
2. It should not be used the next day (change daily).
3. Wash hands well before & after entering the patient’s room.
ADMINISTERING A TUBE FEEDING

Procedure:

1. Introduce yourself, and verify the client’s identity. Explain to the client what you are going to do,
why it is necessary, and how the client can cooperate.
2. Assist the client to a Fowler’s position in bed, or a sitting position in a chair. If a sitting position is
contraindicated, a slightly elevated right- side lying position is acceptable.
3. Perform hand hygiene, and observe other appropriate infection control procedures.
4. Provide for client privacy.
5. Assess the tube placement.
 Attach the syringe to the open end of the tube, and aspirate. Check Ph.
o Allow 1 hour to elapse before testing the Ph, if the client has received medication.
o Use Ph meter rather than Ph paper, if the client is receiving a continuous feeding.
 If the tube was placed in the stomach, aspirate all contents, and measure the amount
before administering the feeding.
 If 100 ml (or more than half of the last feeding) is withdrawn, check with the nurse in charge
or refer to agency policy before proceeding.
 Re-instill the gastric contents into the stomach, if this is the agency policy or the primary
care provider’s order.
 If the client is on a continuous feeding, check the gastric residual every 4-6 hours or
according to agency protocol.
6. Administer the feeding.
 Before administering feeding:
o Check the expiration date of the feeding.
o Warm the feeding to room temperature.
 Remove the bulb from the syringe, and connect the syringe to a pinched or clamped
 Nasogastric tube.
 Add the feeding to the syringe barrel.
 Permit the feeding to flow in slowly at the prescribed rate. Raise or lower the syringe to
adjust the flow as needed. Pinch or clamp the tubing to stop the flow for a minute, if the
client experiences discomfort.
 After feeding, instill 50-100 ml of water through the feeding tube.
 Be sure to add the water before the feeding solution has drained from the neck of a syringe
or from the tubing.
7. Clamp the feeding tube.
 Clamp the feeding tube before all of the water instilled.
8. Ensure client comfort and safety.
 Secure the tubing to the client’s gown.
 Ask the client to remain sitting upright in fowler’s position or in a slightly elevated right
lateral position for at least 30 minutes.
 Check the agency’s policies on the frequency of changing the Nasogastric tube and the use
of smaller-lumen tubes if a large- bore tube is in place.
9. Dispose of equipment appropriately.
 If the equipment is to be reused, wash it thoroughly with soap and water, so that it is ready
for reuse.
 Change the equipment every 24 hours, or according to agency policy.
10. Document all relevant information.
 Document the feeding, including amount and kind of solution taken, duration of the feeding,
and assessment of the client.
 Record the volume of the feeding and water administered on the client’s intake and output
record.
11. Monitor the client for possible complications.
 Carefully assess client’s receiving tube feedings for problems.
 To prevent dehydration, give the client supplemental water in addition to the prescribed
tube feeding, as ordered.
DONNING STERILE GOWNS AND CLOSED GLOVING

PROCEDURE:

1. Don surgical attire and scrub your arms and hands as described.
2. Have the circulating nurse or other designated person open the sterile gown and gloves.
3. Don Gown
4. Pick up and unfold the gown.
5. Identify the inner surface of the gown and pick up the gown beneath the neckband without
touching the sterile field or other surface of the gown.
6. Make sure you have control of all the folded layers to avoid dangling the gown against the
unsterile surfaces.
7. Move away from the tablet, holding the gown away from your body at arm’s length, holding the
gown away from your body at arm’s length and allow it to unfold from the top down. Do not let
the gown touch the floor.
8. Hold the gown just below the neckband near the shoulders and slide both hands into the
sleeves until the fingers are at the end of the cuffs but not through the cuffs. The fingers
remained covered to prepare for the closed gloving.
9. Have someone tie the gown
10. Put on the gloves.
11. Apply the first glove.
12. With your hands covered by the sterile gown cuffs. The first glove goes on the dominant hand
13. Position the glove on the forearm so the cuff faces the hand and the fingers face the elbow.
14. Begin to put the opposite hand into the glover with the sleeve cover of the hand to be gloved.
15. Grasp the back of the glove cuff with the sleeve-covered second hand and turn the cuff over the
sleeve.
16. Push your fingers into the glove.
17. Apply the second glove.
18. Use your sterile hand to pick up the second glove. Put the second glove in the same position as
the first on the opposite forearm.
19. Put on the second glove in the same manner as the first.
20. Adjust the gloves for fit and comfort.
ENTERING AND LEAVING AN ISOLATION ROOM

Procedure:

1. Confirm the type of isolation and apparel required


2. Make sure you have all the supplies you will need for the client before you enter the room
3. Cover hair with cap
4. Put on gown
 Pick up gown by its collar and allow it to unfold without touching the floor
 Slide down over hands and arms by holding arms forward and slightly above head.
 Fasten gown at the back
 Grasp gown at the waistline in back and overlap edges as much as possible.
 (Gown must be large enough to cover your clothing entirely.)
 Secure belt and tie in back.
5. Put on gloves, making sure that cuffs are completely covered.
 Pull the cuff of each glove over the edge of the gown sleeve.
 Interlace fingers, if needed, to adjust the finger of the gloves.
6. Put on mask.
 Position the mask over nose and mouth.
 Bend the nose bar over the bridge of the nose for a snug fit.
 Fasten the elastic bands or tie the mask securely in place if it has strings.
7. Put on googles, if indicated after mask in place.
8. Enter room and perform necessary tasks. Be sure to leave call bell within the client’s reach.
 Ask if you can do anything more before you leave the room
 If the client is an infant, provide good perineal care after each episode of urine and stool; make
sure diaper is clean and dry.
9. After disposing of soiled items used in client care, tie the bag securely. If special disposal methods are
used, and the bag is not pre labeled, mark the bag appropriately.
10. Ensure client safety and comfort before leaving room.
11. Prepare to leave the room.
ROLES AND FUNCTIONS OF THE NURSE
NCM 109 SKILLS

1. CAREGIVER
2. ADVOCATE
3. HEALTH EDUCATOR
4. RESEARCHER
5. TEAM LEADER/MANAGER
6. COORDINATOR/COLLABORATOR
7. TRAINER/FACILITATOR
8. COMMUNITY ORGANIZER
1. CAREGIVER
The caregiver role has traditionally included those activities that assist the client physically and
psychologically while preserving the client’s dignity. Caregiving encompasses the physical, psychosocial,
developmental, cultural and spiritual levels.

2. CLIENT ADVOCATE
Client advocate acts to protect the client. Represent the client’s needs and wishes to other health
professionals, such as relaying the client’s wishes for information to the physician. Assist clients in
exercising their rights and help them speak up for themselves.

BASIS OF NURSING ADVOCACY


 Preserving human dignity
 Patient equality
 Freedom from suffering
3. HEALTH EDUCATOR
Helps the clients learn their health and health care procedures they need to perform, restore or
maintain their health.
Assesses the client’s learning needs and readiness to learn, set specific learning goals in conjunction with
the client, enacts teaching strategies and measures learning

4. RESEARCHER
Research is essential.
It is the only evidence-based method of deciding whether a new approach to treatment or care is better
than the current standard, and is essential to diagnose, treat, prevent, and cure disease. Research
nurses play a vital role in delivering research, and ultimately improving patient care.

ROLE OF A RESEARCH NURSE


 Identifying and screening potential patients
 Making sure that patients have all the necessary information to allow them to make a fully
informed decision about whether they want to participate in a study
 Ensuring that patients give fully informed consent before they are enrolled in a study
 Supporting the Principal Investigator (PI) by coordinating the day-to-day management of
research studies
 Providing on-going support to patients throughout their time as a participant

5. TEAM LEADER/MANAGER
A leader influences others to work together to accomplish a specific goal. The leader role can be
employed at different levels; individual client, family, groups of clients, colleagues, or the community.
Effective leadership is a learned process requiring an understanding of the needs and goals that
motivate people, the knowledge to apply the leadership skills, and the interpersonal skills to influence
others.

QUALITIES OF A GOOD LEADER

6. NURSE MANAGER

The nurse manages the nursing care of individuals, families, and communities. Delegates nursing
activities to ancillary workers and other nurses, and supervises and evaluates their performance.

ROLE OF A NURSE MANAGER TO:

6. COORDINATOR

a. A nurse coordinator supervises and coordinates care for his assigned unit or patients.
b. This is referred to as a charge nurse
c. Ensures that patient care is up to applicable standards and works to make sure the patients in
his care, other staff members, and visitors are safe in the health care environment.
d. Assist with developing care plans for patients and make sure they are carried out according to
the facility's standards.
e. Helps to hire and train new staff members for his unit and provides evaluations of their work as
well. 
f. Helps to hire and train new staff members for his unit and provides evaluations of their work as
well. 
g. Communicates with doctors, patients, and loved ones of patients regarding plans for patient
care.
h. Help establish care plans for the patients in his unit or department and revise them as
necessary.
i. Monitor the health care environment to ensure patient care plans are carried out as expected.
j. Inform other nursing staff members or the doctor in charge of the patient’s treatment, if there
are problems noted with care.
k. Ensure patient responses to treatment are documented as well.
l. Instructs staff members in order to help them provide adequate patient care.
m. Prepares staff evaluations as well.
n. Work to ensure that an adequate number of staff members are available for a particular shift.

6. COLLABORATOR

Collaborative care – is a healthcare model which aims to improve patient outcomes through inter-
professional cooperation.

This will commonly include a primary or tertiary care team working with allied health professionals –
such as dieticians, physiotherapists or mental health professionals – or medical specialists. 

Collaboration - is working with others in a collegial and mutually respectful manner.

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