NURS 111 Check list Inserting a nasogastric tube for gastric ...
NURS 111 Check list Inserting a nasogastric tube for gastric ...
NURS 111 Check list Inserting a nasogastric tube for gastric ...
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Imperial Valley CollegeDivision of Nursing Education and Health TechnologiesNursing <strong>111</strong>: INSERTING A NASOGASTRIC TUBE FOR GASTRIC DECOMPRESSIONRecommendation: Pass __________________________Student _______________________________________Needs Practice ______________________Date ______________________________Instructor ______________________________________ Date ______________________________S= Satisfactory U= Unsatisfactory NP= Needs PracticeASSESSMENTS U NP Comments1. Per<strong>for</strong>med hand hygiene. Inspectedcondition of patient’s nasal and oral cavity. ___ ___ ___ _______________________2. Auscultated <strong>for</strong> bowel sounds. Palpated ___ ___ ___ _______________________patient’s abdomen.3. Assessed patient’s level of consciousnessand ability to follow instructions. ___ ___ ___ _______________________4. <strong>Check</strong>ed medical record <strong>for</strong> order. ___ ___ ___ _______________________5. Prepared equipment at bedside. ___ ___ ___ _______________________6. Identified patient and explained procedure. ___ ___ ___ _______________________7. Per<strong>for</strong>med hand hygiene and appliedclean gloves. ___ ___ ___ _______________________8. Provided privacy ___ ___ ___ _______________________9. Positioned patient in high-Fowler’s positionwith pillows behind head and shoulder.Raised bed to a com<strong>for</strong>table working height. ___ ___ ___ _______________________10. Placed bath towel over patient’s chest.Placed emesis basin within reach. ___ ___ ___ _______________________11. Washed bridge of patient’s nose. ___ ___ ___ _______________________12. Assessed nares <strong>for</strong> most appropriate. ___ ___ ___ _______________________13. Measured distance to insert <strong>tube</strong> fromnose to ear to Xiphoid process. ___ ___ ___ _______________________14. Marked length of <strong>tube</strong> to be inserted fromnares to stomach. ___ ___ ___ _______________________15. Lubricated 7.5 to 10 cm (3 to 4 inches) ofthe end of the <strong>tube</strong> with water-solublelubricating jelly. ___ ___ ___ _______________________
S U NP Comments16. Alerted patient that procedure was aboutto begin. ___ ___ ___ _______________________17. Instructed patient to extend neck, andinserted <strong>tube</strong> slowly through naris withcurved end pointing downward. ___ ___ ___ _______________________18. Continued to pass <strong>tube</strong> along floor ofnasal passage. ___ ___ ___ _______________________19. If resistance met, rotated <strong>tube</strong> orwithdrew <strong>tube</strong>, allowed patient to rest,relubricated <strong>tube</strong>, and inserted intoother naris. ___ ___ ___ _______________________20. With <strong>tube</strong> above oropharynx, instructedpatient to flex head <strong>for</strong>ward and take asip of water if allowed or dry swallow;advanced the <strong>tube</strong> 1 to 2 inches with eachswallow. ___ ___ ___ _______________________21. If patient began to cough, gag, or choke,stopped <strong>tube</strong> advancement; instructedpatient to breathe easily. ___ ___ ___ _______________________22. If patient continued to cough, pulled <strong>tube</strong>back slightly. ___ ___ ___ _______________________23. If patient continued to gag, checked backof oropharynx. ___ ___ ___ _______________________24. After patient relaxed, continued to advance<strong>tube</strong> the desired distance. After <strong>tube</strong> hadbeen advanced, anchored <strong>tube</strong> with preparedsplit tape marked <strong>tube</strong> length. ___ ___ ___ _______________________25. Verified <strong>tube</strong> placement, according to agencypolicy.a. Ask patient to talk. ___ ___ ___ _______________________b. Aspirated gently back on syringe toobtain <strong>gastric</strong> content. ___ ___ ___ _______________________c. Measured pH of aspirate ___ ___ ___ _______________________d. Had x-ray examination of chest andabdomen per<strong>for</strong>med, if ordered. ___ ___ ___ _______________________e. Injected 30cc air into <strong>tube</strong> whileauscultating over epigasture area. ___ ___ ___ _______________________f. If <strong>tube</strong> not in stomach, advanced it 1 to 2inches and repeated steps to check <strong>tube</strong>position. ___ ___ ___ _______________________
S U NP Comments26. Anchoring Tubea. Clamped end or connected to a drainagebag or suction machine. ___ ___ ___ _______________________b. Taped <strong>tube</strong> to nose or applied commercial<strong>tube</strong> fixation device; avoided puttingpressure on nares. ___ ___ ___ _______________________c. Fastened end of NG <strong>tube</strong> to patient’sgown with rubber band and safety pin;provided slack <strong>for</strong> patient’s movement.Maintained pigtail of Salem sump <strong>tube</strong>above level of stomach. ___ ___ ___ _______________________d. Kept head of bed elevated 30 degrees,unless contraindicated. ___ ___ ___ _______________________e. Removed gloves and per<strong>for</strong>med handhygiene. ___ ___ ___ _______________________27. After <strong>tube</strong> placement confirmed,a. Placed mark on tape where <strong>tube</strong> exist nose. ___ ___ ___ _______________________b. Option: Measured <strong>tube</strong> length from naresto connector. ___ ___ ___ _______________________RECORDING AND REPORTING1. Correctly recorded insertion procedure,patient’s tolerance, character of drainage, ___ ___ ___ _______________________and <strong>tube</strong> length ___ ___ ___ _______________________