NURS 111 Check list Inserting a nasogastric tube for gastric ...

Imperial Valley CollegeDivision of Nursing Education and Health TechnologiesNursing 111: INSERTING A NASOGASTRIC TUBE FOR GASTRIC DECOMPRESSIONRecommendation: Pass __________________________Student _______________________________________Needs Practice ______________________Date ______________________________Instructor ______________________________________ Date ______________________________S= Satisfactory U= Unsatisfactory NP= Needs PracticeASSESSMENTS U NP Comments1. Performed hand hygiene. Inspectedcondition of patient’s nasal and oral cavity. ___ ___ ___ _______________________2. Auscultated for bowel sounds. Palpated ___ ___ ___ _______________________patient’s abdomen.3. Assessed patient’s level of consciousnessand ability to follow instructions. ___ ___ ___ _______________________4. Checked medical record for order. ___ ___ ___ _______________________5. Prepared equipment at bedside. ___ ___ ___ _______________________6. Identified patient and explained procedure. ___ ___ ___ _______________________7. Performed 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 comfortable 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 for most appropriate. ___ ___ ___ _______________________13. Measured distance to insert tube fromnose to ear to Xiphoid process. ___ ___ ___ _______________________14. Marked length of tube to be inserted fromnares to stomach. ___ ___ ___ _______________________15. Lubricated 7.5 to 10 cm (3 to 4 inches) ofthe end of the tube with water-solublelubricating jelly. ___ ___ ___ _______________________

S U NP Comments16. Alerted patient that procedure was aboutto begin. ___ ___ ___ _______________________17. Instructed patient to extend neck, andinserted tube slowly through naris withcurved end pointing downward. ___ ___ ___ _______________________18. Continued to pass tube along floor ofnasal passage. ___ ___ ___ _______________________19. If resistance met, rotated tube orwithdrew tube, allowed patient to rest,relubricated tube, and inserted intoother naris. ___ ___ ___ _______________________20. With tube above oropharynx, instructedpatient to flex head forward and take asip of water if allowed or dry swallow;advanced the tube 1 to 2 inches with eachswallow. ___ ___ ___ _______________________21. If patient began to cough, gag, or choke,stopped tube advancement; instructedpatient to breathe easily. ___ ___ ___ _______________________22. If patient continued to cough, pulled tubeback slightly. ___ ___ ___ _______________________23. If patient continued to gag, checked backof oropharynx. ___ ___ ___ _______________________24. After patient relaxed, continued to advancetube the desired distance. After tube hadbeen advanced, anchored tube with preparedsplit tape marked tube length. ___ ___ ___ _______________________25. Verified tube placement, according to agencypolicy.a. Ask patient to talk. ___ ___ ___ _______________________b. Aspirated gently back on syringe toobtain gastric content. ___ ___ ___ _______________________c. Measured pH of aspirate ___ ___ ___ _______________________d. Had x-ray examination of chest andabdomen performed, if ordered. ___ ___ ___ _______________________e. Injected 30cc air into tube whileauscultating over epigasture area. ___ ___ ___ _______________________f. If tube not in stomach, advanced it 1 to 2inches and repeated steps to check tubeposition. ___ ___ ___ _______________________

S U NP Comments26. Anchoring Tubea. Clamped end or connected to a drainagebag or suction machine. ___ ___ ___ _______________________b. Taped tube to nose or applied commercialtube fixation device; avoided puttingpressure on nares. ___ ___ ___ _______________________c. Fastened end of NG tube to patient’sgown with rubber band and safety pin;provided slack for patient’s movement.Maintained pigtail of Salem sump tubeabove level of stomach. ___ ___ ___ _______________________d. Kept head of bed elevated 30 degrees,unless contraindicated. ___ ___ ___ _______________________e. Removed gloves and performed handhygiene. ___ ___ ___ _______________________27. After tube placement confirmed,a. Placed mark on tape where tube exist nose. ___ ___ ___ _______________________b. Option: Measured tube length from naresto connector. ___ ___ ___ _______________________RECORDING AND REPORTING1. Correctly recorded insertion procedure,patient’s tolerance, character of drainage, ___ ___ ___ _______________________and tube length ___ ___ ___ _______________________