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Fundamentals study guide

Terms in this set (53)

- Check the physicians order
- Check electrolyte balance
- Check use of ASA or other anti-coagulants
- Check for tolerance to any previous NG tube or tube feeding
-Wash hands
-Collect needed equipment
-NG tube
-stethoscope
-cup of ice chips/water
-tape
-piston-tip syringe
-non-sterile gloves
-tissues and a towel
-formula @ room temp.
-pen light
-tongue blade
-Enter room
-Identify patient
-Explain procedure to patient
-Determine how the patient would communicate during the procedure
-Lower side rail on nurses side
-ASSESS:
-Level of consciousness
-Swallowing ability (gag reflex)
-Abdominal size, auscultate bowel sounds, percuss and palpate if needed
-Nostril patency
-Hydration status (skin turgur)
-Position patient in semi- or high-Fowler's position
-Remove and glasses or dentures
-Put on clean gloves
-Measure from nose to ear to zyphoid process
-Mark measurements with a pen
-Prepare tape for securing NG tube
-Lubricate the tip of the tube
-Instruct the patient to swallow ice chips/water as soon as he feels the tube in the back of the throat
-Insert lubracated tube into the selected nostril, when the tube reaches the posterior of the nostril, have the patient flex head down toward chest
-Continue to advance the tube quickly as the patient swallows until the marked site is achieved
-If patient chokes, gets short of breath, or becomes cyanotic quickly pull tube out!!
-Do not force the tube!!
-After insertion temporarily secure to side of face and check placement
-10 cc air bolus is inserted while auscultating epigastric area
-aspirate for gastric contents and replace contents
-schedule X-ray to confirm placement
-Secure to bridge of nose with tape
-Depending on orders: a. clamp tube, b. schedule x-ray, c. connect to suction, Reposition patient for comfort and safety, Document: