Nursing Review: Nasogastric Tube (NGT)

Nasogastric Tube (NGT)

Ø  Gavage (feeding) / Lavage (suctioning)

Ø  Select the nostril that has greater airflow.

Ø  Assist the client to a high fowler’s position

Ø  NEX technique (nose-ear-xiphoid)

Ø  Checking the patency:

ü  Aspirate stomach contents and check the pH, which should be acidic

ü  Introduce 10-30 ml of air into the NGT and auscultate at the epigastric area, gurgling sound is heard

ü  The most accurate method of assessing the placement of NGT is X-ray study

Ø  Before feeding assess residual feeding contents. To assess absorption of the last feeding, if 50 ml or more, verify if the feeding will be given.

Ø  Height of feeding is 12 inches above the point of insertion.

Ø  Ask the client to remain in position for at least 30 min

Ø  Common Problems of Tube Feedings

·         Vomiting

·         Aspiration

·         Diarrhea

·         Hyperglycemia

read more

Nursing Review: Urinary Catheterization

Urinary Catheterization

Ø  Use appropriate size of catheter

• Male: Fr 16-18
• Female: Fr 12-14

Ø  Place the client in appropriate position:

• Male: Supine, legs abducted and extended
• Female: Dorsal recumbent

Ø  Locate the urinary meatus properly:

• Male: at the tip of the glans penis
• Female: between the clitoris and vaginal orifice

Ø  Lubricate catheter with water soluble lubricant before insertion

• Male: 6 – 7 inches
• Female: 1 – 2 inches

Ø  Length of catheter insertion:

• Male: 6 – 9 inches
• Female: 3 -4 inches

Ø  Anchor catheter properly:

• Male: laterally or upward over the lower abdomen / upper thigh
• Female: inner aspect of the thigh

Nursing Interventions to Induce Voiding/Urination

v  Provide privacy

v  Assist the patient in the anatomical position of voiding

v  Serve clean, warm and dry bedpan (female) or urinal (male)

v  Allow the client to listen to the sound of running water

v  Dangle fingers in warm water

v  Pour warm water over the perineum

v  Promote relaxation

v  Provide adequate time for voiding

v  Last resort: URINARY CATHETERIZATION

read more

Nursing Review: Vital Signs

Vital Signs

 Ø  Temperature (NV 36 – 37.5 C)

ü  Elderly people are at risk of hypothermia

ü  Hard work or strenuous exercise can increase body temperature

ü  Oral: most accessible 2-3 mins. * 15 minutes interval after ingestion of hot or cold drinks

ü  Rectal: most accurate 2-3 mins.

ü  Axillary: most safest 6-9 mins.

Ø  Pulse (NV 60-100 bpm)

   ü  Wave of blood created by contraction of the left ventricle of the heart

   ü  Radial: best site for adult

   ü  Brachial: best site for children

   ü  Apical: best site for 3 years old below

Ø  Respiration (NV 12/16-20)

Normal Breath Sound

Vesicular	Soft, low pitch	Lung periphery
Broncho-vesicular	Medium pitch	Larger airway blowing
Bronchial	Loud, high pitch	Trachea

Abnormal Breath Sound

Crackles	Dependent lobes	Random, sudden reinflation of alveoli fluids
Rhonchi	Trachea, bronchi	Fluids, mucus
Wheezes	All lung fields	Severely narrowed bronchus
Pleural Friction Rub	Lateral lung field	Inflamed Pleura

Ø  Blood Pressure (NV 120/80 mm/hg)

  ü  This is the force exerted by the blood against a vessel wall

  ü  The pressure rises with age.

  ü  A rest of 30 minutes is indicated before the blood pressure can be readily assessed 

             after stressful activity.

  ü  Interval of 30 minutes is needed after smoking or drinking caffeine.

  ü  After menopause, women generally have higher blood pressures than before.

  ü  Pressure is usually lowest early in the morning, when the metabolic rate is lowest, 

             then rises throughout the day and peaks in the late afternoon or early evening

Common Errors in Blood Pressure Assessment

Errors	Effect
Bladder cuff too narrow	Erroneously high
Bladder cuff too wide	Erroneously low
Arm unsupported	Erroneously high
Insufficient rest before the assessment	Erroneously high
Repeating assessment too quickly	Erroneously high
Cuff wrapped too loosely or unevenly	Erroneously low
Deflating cuff too quickly	Erroneously low systolic and high diastolic reading
Deflating cuff too slowly	Erroneously high diastolic reading
Failure to use the same arm consistently	Inconsistent measurements
Arm above level of the heart	Erroneously low
Assessing immediately after a meal or while client smokes	Erroneously high
Failure to identify auscultatory gap pressure	Erroneously low systolic pressure and erroneously low diastolic

read more

Nursing Review: Isolation Precautions

 

Standard Precautions / Universal Precautions

Applies to ALL BODY FLUIDS

Includes:

1.      HAND WASHING

2.      Personal Protective Equipment

(sequence of removing PPE’s)

gloves-mask-gown-eyewear-cap

3.      Safe use of sharps

4.      Removing spills of blood and body fluids

5.      Cleaning and disinfecting equipment

Transmission Based Precautions

• Airborne precautions

1. A single room under negative pressure ventilation with a wash hand basin
2. The door must be kept closed at all times except during necessary entrances and exits.
3. Disposable paper towels
4. A high efficiency mask, if available, should be worn when entering the room of a patient with known or suspected tuberculosis.

• Droplet precautions

Put on a standard mask prior to entering the isolation room. 

Hands must be washed with an antiseptic preparation and must be dried thoroughly with a disposable paper towel or washed with a waterless alcohol hand rub/gel:

1.      AFTER contact with the patient or potentially contaminated items, 

2.      AFTER removing gloves, and

3.      BEFORE taking care of another patient.

• Contact precautions

1. Non-sterile, disposable gloves are needed when there is contact with an infected site, with dressings, or with secretions.
2. A mask when performing procedures that may generate aerosols or when performing suctioning is recommended.
3. Hands washing (see droplet precautions)

read more