Skills: Airway/NG/Ostomy

surgically formed opening into the abdominal wall to allow for fecal elimination

• -to give physical and psychological support to the patient (and their family) with an ostomy
•       *encourage the pt to participate in care and to look at the ostomy
•       *keep the skin around the stoma site clean and dry
•       *keep the patient free from odors as much as possible
•       *maintain appropriate intake and output
•       *patient teaching

1/3 to 1/2 full with stool or air

• -safe entry
• -waterproof pad under ostomy bag
• -hold end of pouch up
• -remove clamp
• -fold end of bag over like a cuff
• -empty contents into collection container
• -use squeeze bottle to squirt water in pouch to rinse it out
• -use tissue to wipe lower 2 inches
• -uncuff end and apply clamp
• -patient may use some sort of deodorizer

every 3-7 days

• -ID patient
• -Wash hands/don gloves
• -Explain procedure
• -Put bed to good height
• -Waterproof pad under patient
• -Clean area with soap and water
• -Pat dry
• -Assess stoma
• -Apply skin barrier
• -Measure stoma opening
• -Cut Hole 1/8 in larger than opening
• -Use paste to fill in area between appliance and stoma to protect the skin
• -Snap pouch on
• -Document appearance of stoma, condition of skin, drainage and how patient tolerated procedure

• Functional gastrointestinal tract with suffiecient length and absorptive capacity and the inability to take nutrients through the oral route totally or in part
•     -impaired swallowing
•     -major trauma
•     -burns
•     -critical illness

A poor gag reflex

decompression, compression, or gastric lavage

Large bore NG tube that has the pigtail (air vent) which allows for free, continuous drainage of secretions through the main lumen....

Irrigate, Clamp Off, or Connect to Suction

Large bore NG tube for compression to stop bleeding

Usually used for gastric decompression or removal of gastric secretions and gastric lavage

used for medication administration and tube feedings

Small Bore NG Tube that has a wire stylett that helps guide....used for medication, enteral nutrition.

*ALWAYS have X-Ray confirmation of placement

• ID patient
• Explain procedure
• Wash Hands
• Assess Patient
•    -determine contraindications: polyps, nose bleeds, deviated septum, history aspiration, nasal surgery, anticoagulants, trauma
•    -inspect nares with penlight
•    -have patients occlude one nare and breathe through the opposite nare (repeat on other side)
•    -test gag reflex with tongue blade
• Gather Supplies
•     -HAVE SUCTION available
• Position Pt in HIGH fowlers
• Raise Bed to Good Working Height
• Hand Patient Emesis Basin
• Open Tube
• Place Water Soluble lubricant on paper
• Don Clean Gloves
• Measure Tube
•     -from Nose to Earlobe to Xiphoid Process
• Mark tube with piece of tape of indelible marker
• Lubricate the tube
• Have pt. extend head back
• Have pt swallow as you pass the tube
• Use penlight to check mouth
• Tape anchor tube in place
• Be sure air vent is above level of stomach
• VERIFY PLACEMENT
• Return bed to lowest position 
•     -keep HOB between 30-45 degrees
• Provide oral hygiene every 2-4 hours
• Document

• X-ray 
•     -needs doctor's order, but is most reliable

Assess lung sounds

• Insert Air and assess for bowel sounds
•     -not as reliable, but inserting air may make it easier to withdraw gastric contents

• Withdraw and visualize gastric content
•     -grassy, green/brown, clear or mucusy

Check Ph < 5

• CO2 detector
•      -if it is positive you are in the lungs

• Put end of tube into glass of water and watch for bubble
•     -proven unreliable

Length of tube should remain constant

Gasping, Coughing, Cyanosis, Inability to speak or hum

20-40 mm Hg

Every 4 Hours

• ID patient
• Elevate HOB
• Wash hands/don gloves
• Pour irrigation solution into container
• Disconnect from suction
• Measure length of exposed tube
•     -this allows you to observe for a change in the external length
• Aspirate stomach contents and check pH
• Insert 30 ml of irrigating solution by gravity or pushing gently
• Withdraw manually or reconnect to suction
• Not characteristics of return solution
• Can inject air into air lumen to be sure it's clear

• Frequently inspect nares for irritation, redness, breakdown or ulceration 
•      -can lubricate around nares
• If nare is breaking down, remove NG tube and place in other nare or find another route
•     -check with provider
• Provide frequent mouth care
•     -encourage pt. to brush teeth and lubricate lips
• If throat hurts, get analgesic spray
• Check hospital policy for how often to:
•      -check placement (usually 4-6 hrs)
•       -check residual
•       -flush tubing (may modify based on fluid restrictions)
•       -change dressing

Assess for bowel sounds, flatus and return of appetites

Place towel or waterproof pad over pt chest

ID patient/Explain procedure

Wash Hands/Don Gloves

Raise bed to working height

Disconnect from suction

Untape from nose and detach from gown

If the NG has a balloon be sure to deflate it

Hospital policy may or may not have you check for residual

Have pt take deep breath and hold it

Pinch and remove tube

Inspect tube

Offer Mouth Care

Observe pt for gastric distention, N/V

NG tube, PEG tube, J-tube, GI tube

Used when nutrients need to be given directly into the GI tract and bypass mouth/swallowing

Attach barrel/syringe or end of feeding bag to feeding tube

Elevate approximately 12in. above stomach and allow to go in by gravity until amount ordered has gone in (the height of the syringe will regulate how fast or slow it goes in)

Flush with 30ml of water

Disconnect from tubing and cap tubing

Have Patient Sit Upright for 60 Minutes After Feeding is Completed!

every 4-6 hours

30-45 degrees

• Pros:
•    *Gradual introduction of formula into GI tract
• Cons:
•    *Limits mobility, needs pump increasing cost, increased risk for reflux and aspiration

• Pros:
•    *Resemble a more normal pattern of intake and allows for more freedom of movement
• Cons:
•    *May cause overdistention, leading to nausea, diarrhea, cramping, or even dumping syndrome

When administering food for a portion of a 24 hour (usually during the night allowing for freedom during the day)

• -if a pt is gasping for air or unable to speak
• (Remove tube immediately and assess status/VS)

• -if you are unable to flush the tube
• (try to reposition the patient and try to inject air which may move tube away from stomach wall)

• -Clogging
• (prevent by flushing with cranberry juice, cocacola, meat tenderizer or WARM WATER)

• Misconnection Occurs
• The tube is misplaced/displaced
• Aspiration occurs
• GI intolerance related to formula contamination
• Drug-nutrient interactions

• Ordering -- right formula, rate, tube
• Preparation -- aseptic technique
• Delivery -- correct tube placement and HOB elevated
• Monitoring -- change tubing every 24hr, check residual

• Can put liquid medications or medications that can be crushed and combined with liquid
• down the tube.

Make sure medication is compatible with formula

Place patient in high-fowlers position.  Keep HOB elevated for at least 1 hour after medication is administered

Verify placement of tube confirming with at least 2 methods

If the tube is connected to suction disconnect the tube and leave it clamped for 20-30 minutes after administering the medication.

If the patient is on continuous tube feeding, then clamp for 30 minutes, flush,  give medication, flush, resume feeding 30 minutes to 1 hour after.  If medication is not compatible than a minimum of 30 minutes to hold feeding is a must!

Give each medication separately.

Use syringe as a funnel

Flush with water before, between and after each medication.  The amount is determined by patients age, size, medication order and hospital policy.

Adults are usually 30 ml of water

Document medication and flush as part of intake.

Checking placement by measuring tubing that is outside abdomen

• Care of the insertion site would include:
• ◦Clean around site with warm water or ½ strength H2O2

◦If external disk rotate 90° once a day

◦If drainage can use zinc oxide  to prevent breakdown

◦Use split gauze to absorb secretions

◦Check routinely for pain, redness, drainage, if disk is digging into skin

Done to provide comfort by clearing the air passages and decreasing the work of breathing *helps improve oxygenation

Used with patients that are unable to remove secretions with coughing

Verify doctor’s orders

Wear PPE

You may have to pre-medicate the patient with pain meds

ID patient

Explain procedure

Put bed to good working height

Assess nasal passages.  Check for history of problems such as deviated septum, polyps

• Assess lung sounds- suctioning should only be done if secretions have accumulated or
• there are adventitious breath sounds

Wash hands and don PPE  (gown, mask)

Position patient

Place waterproof pad across patient’s chest

Verify suction is working and set at 80 -120 mm Hg [too high pressure can cause trauma]

Sterile procedure: Your dominant hand will remain sterile and your non-dominant hand will be your clean hand

Open package. Remove container and pour saline in container (a little different from video)

Don sterile gloves

Remove suction catheter from package

Secure catheter to tubing with non-dominant hand

Lubricate tubing in normal saline and check suction by occluding port

If patient is on oxygen have them take a few deep breaths, then remove oxygen using non-dominant or clean hand

Measure tubing from earlobe to nostril without touching it to patient or insert into nare 6-8” WITHOUT APPLYING SUCTION

Apply intermittent suction with thumb and rotate catheter while withdrawing for a maximum total time of 10-15 seconds

If on oxygen, allow patient to breath in oxygen in between passes

Clear tubing with normal saline and repeat, waiting 30 seconds – 1 minute in between passes (can wrap tubing around hand between passes)

Do not go down more than 3 times

Reapply oxygen

Dispose of supplies

Assess lung sounds

Document before and after lung sounds, characteristics and amount of secretions, how patient tolerated procedure

Same as Nasopharyngeal Suctioning EXCEPT:

• ◦To hyper-oxygenate your patient, at the beginning and in between passes, you will
• need to bag them rather than them taking deep breaths so you will need an ambu bag
• giving 3-6 breaths

• ◦When inserting catheter you will go until you meet resistance or patient begins to
• cough, pull back slightly [approx 1”], then start suctioning as you withdraw the catheter (usually 4-5”)

◦Patient may need to rest for 1 minute in between passes

• ◦Place oxygen device back over patient stoma rather than face

-A patient that has a trach is unable to speak (consider their inability to communication and keep communication tools close at hand)

-Make sure Call bell is in reach

-Offer frequent reassurance

-Try to anticipate patient's needs