Foundations Exam 1 Wk 7

• 1. Perform preliminary actions
• 2. Prepare the equipment.
• a. Arrange all equipment on a small table or bedside stand.
• b. Prepare the dressing needed to secure the tube to the client's nose. If using tape, tear a 3-inch strip of 1-inch tape and make a 1 1/2-inch horizontal tear up the center of this strip. If using a clear occlusive dressing, open the package.
• c. Check the suction apparatus. Attach the collection device to the suction apparatus and the tubing. Make sure the lid is on the canister tightly and turn on the suction to confirm a pressure of 80 to 100 mm Hg.
• 3. Prepare the client.
• a. Place the client in a position that enhances the client's ability to assist you by swallowing. Usually, high Fowler's position (head of the bed elevated 60 to 90 degrees) is the best position to allow the client to bring his or her head forward to swallow. If this position is contraindicated or the client is unconscious, it may be necessary to keep him in a recumbent position.
• b. Determine which of the client's nostrils is most open. Occlude one of the client's nostrils and listen while he or she breathes through the other nostril. Repeat the process on the opposite side to compare openness. Also inspect the nose for septal deviation, ask the client about any history of a broken nose or problems with past intubations, if applicable.
• 4. Pass the tube.
• a. Find the proper length for the nasogastric tube by measuring from the client's nose to the earlobe and then to the xiphoid process.
• b. Mark the length of tube to be passed with a small piece of tape partially around the tube, and then lubricate the final 3 inches at the tip of the tube.
• c. With the client's head in a neutral position, insert the tube through the client's most patent nostril and pass it through to the nasopharynx. Have the client tilt the head slightly forward while holding the water glass in one hand. Grasp the lubricated tube with your dominant hand about 6 inches from the end. Place your forefinger on the top and your thumb on the bottom. When you reach the posterior part of the nostril, press your thumb and forefinger together to bend the tube, thus facilitating advancement past the sharp curvature of the nasopharynx.
• d. Once you clear the client's epiglottis, have the client bend the head forward (touching chin to chest), advance the tube until you reach the tape marker, indicating that the tube has reached the stomach. The client's epiglottis must be closed as the tube passes to prevent the tube from entering the trachea. Ask the client to sip water through the straw and, each time the client swallows, advance the tube. If the client cannot swallow, have the client hold his or her breath to close the epiglottis. If the client is unconscious, watch his or her respirations. If the client begins coughing or becomes cyanotic at any time, remove the tube immediately. If the client gags or vomits, stop advancing the tube but leave it in place if possible. Give the client an emesis basin, if appropriate, and allow the client to rest for a moment.
• 5. Connect the tube to suction, and ensure client safety.
• a. Tape the tube to the nose using only one side of the split tape to maintain the position while verifying placement
• b. Verify tube placement in the stomach. Attach the cone-shaped syringe to the tubing, and aspirate for gastric secretions. If no gastric secretions appear, advance the tube 2 inches more and repeat the test. Gastric secretions are usually greenish to off-white unless a bleeding problem exists, which may be presented as bright red or brownish secretions.
• c. Check for gastric pH by aspirating stomach contents and dipping the pH test strip into the contents. Contents from the stomach usually have a pH of less than 5. Although usually a good indicator, medications as well as blood can alter the pH.
• d. Use the five-in-one connector to attach the distal end of the tube to the tubing marked “to patient” on the lid of the suction collection device.
• e. Finish taping the tube to the client's nose using the method specified by your facility.
• f. Attach the tubing to the gown with a rubber band and safety pin. By leaving some slack in the tube when you affix it to the gown, you can prevent accidental pulling on the tube when the client turns his or her head.
• g. Set the suction control at the prescribed level. Usually, you will use low intermittent suction (80 to 120 mm Hg) for an adult. Only with a double-lumen tube can you safely use high suction (>120 mm Hg). This is because the second lumen allows constant air exchange and thus prevents gastric tissue trauma from the high suction pressure. The second lumen must be kept clear of secretions to decrease this risk. If you notice secretions in the second lumen, instill about 10 to 20 mL of air into it to displace the secretions.
• 6. Finish the procedure.
• a. Document the reason for the NG tube, your collaboration with the physician, the actual procedure, and the client's response. Documentation is essential to validate care and provide data for future comparison and follow-up.
• b. Provide comfort care for the client's nose and mouth at least every 8 hours and as needed. Use a clean cotton-tipped swab and water-soluble lubricant to clean the client's nostril. Assess the amount and characteristics of the nasogastric drainage as you provide care. Avoid alcohol-based mouth care agents for oral care because they tend to promote dryness.
• 7. Monitor the client.
• a. Inspect the client's abdomen, and auscultate bowel sounds at least every 8 hours. To decrease the possibility of mistaking suction sounds for bowel sounds, pinch the suction tubing as you auscultate the client's abdomen.
• b. Monitor and document the amount and characteristics of the client's NG output, manifestations of deficient fluid volume, low electrolyte levels (especially sodium, potassium, calcium, chloride, and magnesium), or plasma levels that suggest deficient fluid volume (elevated sodium, blood urea nitrogen, and hematocrit).
• c. Notify the physician if the client's NG output exceeds 100 mL/hr, if total output exceeds total intake, or if there are new or worsening signs of deficient fluid volume. Signs of deficient fluid volume include hypotension, a pulse of more than 20 beats per minute above the client's baseline when resting, urine production of less than 30 mL/hr for 2 consecutive hours or more, seizures, confusion, sudden behavioral changes, and abnormal electrolyte levels.
• d. If the client's NG tube stops draining well, first assess the equipment for function errors. If this is not the problem, consult a physician for an irrigation order. Irrigate the tube using a 50- or 60-mL cone-shaped syringe with 30 to 60 mL of normal saline. Repeat as necessary. Normal saline is the only acceptable irrigating solution because its isotonicity will not further compromise the client's fluid and electrolyte balance. Make sure to compute the difference in the amount of irrigant instilled and the amount removed; subtract or add that figure to the client's 8-hour nasogastric drainage total.

Check gastric residual volume (GRV) before giving a feeding, or every 4 hours with continuous feedings. There is no consensus in the literature about when to withhold feedings but this should be done if the GRV is greater than 400 mL

special care should be given to a patient with a feeding tube because they are at a high risk for aspiration, also monitor residual, placement, and ensure equipment is changed within the guidelines of facility policy