ADMINISTERING A TUBE FEEDING
Purpose
To restore or maintain nutritional status
To administer medications
Equipment
Correct type and amount of feeding solution
60ml catheter tip syringe
Emesis basin
Clean gloves
Stethoscope
Measuring container
60ml water
Goal
The patient receives the tube feeding without complaints of nausea or episodes of
vomiting.
Criteria Done Not Remarks
done
ASSESSMENT
1. Assess client for food allergy
2. Auscultate for bowel sounds before feeding.
3. Verify physician’s order’s for formula, route, frequency
PLANNING
1. Assemble equipment. Check amount, concentration, type, and
frequency of tube feeding on patient’s chart.
2. Check expiration date of formula.
3. Remove formula from refrigerator to allow to come to room
temperature
IMPLEMENTATION
1. Perform hand hygiene. Put on gloves before preparing,
assembling and handling any part of the feeding system.
2. Identify the patient.
3. Explain the procedure to the patient and why this
intervention is needed. Answer any questions as needed.
4. Assemble equipment on over bed table within reach.
5. Close the patient’s bedside curtain or door. Raise bed to a
comfortable working position, usually elbow height of the
caregiver (VISN 8, 2009). Perform key abdominal assessments as
described above.
6. Position patient with head of bed elevated at least 30 to45
degrees or as near normal position for eating as possible.
7. Put on gloves. Unpin tube from patient’s gown. Verify the
position of the marking on the tube at the nostril. Measure
length of exposed tube and compare with the documented
length.
8. Attach syringe to end of tube and aspirate a small amount of
stomach contents:
Measure the pH of aspirated fluid using pH paper or a
meter. Place a drop of gastric secretions onto pH paper or
place small amount in plastic cup and dip the pH paper into
it. Within 30 seconds, compare the color on the paper with
the chart supplied by the manufacturer.
Visualize aspirated contents, checking for color and
consistency.
9. If it is not possible to aspirate contents; assessments to check
placement are inconclusive; the exposed tube changed; or there
are any other indications that the tube is not in place, check
placement by x-ray.
10. After multiple steps have been taken to ensure that the feeding
tube is located in the stomach or small intestine, aspirate all
gastric contents with the syringe and measure to check for the
residual amount of feeding in the stomach. Return the residual
based on facility policy. Proceed with feeding if amount of
residual does not exceed agency policy or the limit indicated in
the medical record.
11. Flush tube with 30 mL of water for irrigation. Disconnect
syringe from tubing and cap end of tubing while preparing the
formula feeding equipment.
12. Administer feeding.
USING A LARGE SYRINGE (OPEN SYSTEM)
Remove plunger from 30- or 60-mL syringe.
Attach syringe to feeding tube, pour premeasured amount
of tube feeding formula into syringe, open clamp, and allow
food to enter tube. Regulate rate, fast or slow, by height of
the syringe. Do not push formula with syringe plunger.
Add 30 to 60 mL (1–2oz) of water for irrigation to syringe
when feeding is almost completed, and allow it to run
through the tube.
When syringe has emptied, hold syringe high and
disconnect from tube.
Clamp tube and cover end with cap.
13. Observe the patient’s response during and after tube feeding
and assess the abdomen at least once a shift.
14. Have patient remain in upright position for at least 1 hour after
feeding.
15. Remove equipment and return patient to a position of comfort.
Remove gloves. Raise side rail and lower bed.
16. Put on gloves. Wash and clean equipment or replace according
to agency policy. Remove gloves.
17. Remove gloves. Perform hand hygiene.
EVALUATION
1. Evaluate patient’s response to the procedure.
DOCUMENTATION
1. Document the type of feeding, feeding formula, amount
administered, residual gastric contents prior to feeding and
patient response to the procedure.
Evaluator
________________________ ________________________ ________________________
Clinical Instructor’s Name Student’s Name and Date
and Signature Signature
ADMINISTERING GASTRIC LAVAGE
Purpose
Remove unabsorbed poison after ingestion.
Diagnosis and stop gastric hemorrhage.
Clean stomach before diagnostic procedures.
Remove liquid or small particles of material from stomach.
Equipment
Nasogastric insertion equipments.
Lavage fluid – NaCl or other prescribed solution.
Syringe 20ml for aspiration and 60ml for lavage.
Specimen container with lab request form.
Kidney basin as receiver.
Measuring cup
Goal
The patient receives the tube feeding without complaints of nausea or episodes of
vomiting.
Criteria Done Not Remarks
done
ASSESSMENT
1. Verify doctor’s order
2. Assess patient’s level of consciousness
3. Assess baseline vital signs, abdominal girth, and bowel
sounds.
PLANNING
1. Obtain all supplies. Assemble equipment.
2. Provide for privacy.
IMPLEMENTATION
1. Perform hand hygiene. Don gloves.
2. Identify the patient.
3. Explain the procedure. Instruct client to report any pain,
difficulty breathing, or other problems during the
procedure.
4. Place in semi-Fowler’s or Fowler’s position. If hypotension
is present, place in left side-lying position.
5. Insert a nasogastric (NG) tube (14 to 16 French, unless other-
wise indicated) if one is not already in place, and verify
placement.
6. Empty the stomach using suction or a 60-mL catheter-tip
syringe. Measure, collect for specimen sample and discard
remaining aspirate.
7. Record input and output throughout the procedure
8. Using the syringe, draw up approximately 50 mL of
irrigation solution, and instill it using gentle pressure.
9. Withdraw and discard the solution into a measuring
container.
10. Continue until the desired amount of irrigant or desired
results have been obtained.
11. Monitor vital signs, respiratory status, and client tolerance
during the procedure.
12. Label specimens and dispatch to laboratory immediately
13. Remove additional PPE, if used. Perform hand hygiene.
EVALUATION
14. Evaluate patient’s response to the procedure.
DOCUMENTATION
2. Document the type and amount of irrigating solution, color of
gastric contents, presence of bleeding, and patient’s response to
the procedure.
Evaluator
________________________ ________________________ ________________________
Clinical Instructor’s Name Student’s Name and Date
and Signature Signature
OBTAINING A CAPILLARY BLOOD SAMPLE FOR GLUCOSE TESTING
Purpose
To determine or monitor blood glucose levels of clients at risk for hypoglycemia or
hyperglycemia
To promote blood glucose monitoring by the client
To evaluate the effectiveness of insulin administration
Equipment
Blood glucose meter (glucometer)
Blood glucose reagent strip compatible with the meter
2x2 gauze
Antiseptic swap
Disposable gloves
Sterile lancet
Lancet injector
Goal:
The blood glucose level is measured accurately without adverse effect.
Criteria Done Not Remarks Rating
done
ASSESMENT
1. Determine the frequency and type of testing,
understanding of the procedure and client’s
response to previous testing
2. Assess the client’s skin at the puncture site to
determine if it is intact, circulation is not impaired,
color, warmth and capillary refill
PLANNING
1. Review the type of meter and the manufacturer’s
instructions. Assemble all the equipment at the
bedside.
2. Introduce oneself to the patient, provide for client
privacy and explain to the client what you are
going to do, why is it necessary and how she can
cooperate.
3. Perform hand hygiene and observe appropriate
infection control procedures.
IMPLEMENTATION
1. Prepare the glucometer and lancet using aseptic
technique.
2. Put on gloves.
3. Select and prepare the puncture site.
Adult: usually the side of an adult’s finger (the
middle and fourth finger are the best choices,
the second finger is usually the most sensitive
and thumb may have thickened skin or calluses
and avoid using a ring bearer finger.)
Infant: usually the heel or great toe.
4. If necessary wrap the finger first in a warm cloth or
hold the finger in a dependent position. These
actions increase the blood flow to the area, ensure
adequate specimen, and reduce the need for a
repeat puncture.
5. Clean the site with the antiseptic swab or soap and
water and allow it to dry completely. Alcohol can
affect accuracy and the site burns when punctured
when wet with alcohol.
6. Place the lancet injector against the site and release
the needle to pierce the skin. Make sure the lancet
is perpendicular to the site. The lancet is designed
to pierce the skin at a specific depth when it is in a
perpendicular position relative to the skin.
7. Prick the site using a darting motion.
8. Gently squeeze (but careful not to touch the
puncture site) until a large drop of blood forms.
9. Hold the reagent strip under the puncture site
until adequate blood covers the indicator square.
10. Ask the client to apply pressure to the skin
puncture site with a 2x2 gauze. Pressure will
assist hemostasis.
11. Measurement varies according to the type of
glucose meter you are using.
Standardized color chart:
Make sure leave the blood on the strip for
the amount of time required by the
standardized color chart or glucometer.
A reagent patch on the tip of a hand held
plastic strip changes color in response to
the amount of glucose in the blood sample.
Interpret the color in the reagent strip to
the standardized color chart obtained.
Portable Glucose Meter:
Follow the manufacturer’s instructions,
meter designs vary, but they all analyze a
drop of blood on a reagent’s strip that
comes with the unit and provide of a
digital display of the resulting glucose
level. Obtain result.
12. Do after care. Dispose of the lancet according to
the hospital policy.
13. Remove gloves and wash hands
EVALUATION
1. Evaluate test result, notify physician if outside the
expected parameters.
DOCUMENTATION
1. Record the reading from the reagent strip (using of
portable blood glucose meter or a color chart) on
nurse’s notes or on a special flowchart if available.
2. Record the time and date of the test.
Evaluator
________________________ ________________________ ________________________
Clinical Instructor’s Name Student’s Name and Date
and Signature Signature
COLOSTOMY CARE (CHANGING AN OSTOMY APPLIANCE)
Purpose
To assess and care for the peristomal skin.
To collect stool for assessment of the amount and type of output.
To minimize odors for the client’s comfort and self-esteem.
Equipment
Clean gloves
Bedpan
Moisture-proof bag (for disposable pouches)
Cleaning materials, including warm water, mild soap (optional), washcloth or towel,
wash basin
Skin barrier (optional)
Stoma measuring guide
Pen or pencil and scissors
New appliance or ostomy pouch with optional belt
Tail closure clamp
Tissue or Gauze pad
Adhesive tape
Deodorant for pouch (optional)
Procedures Done Not Remarks
Done
ASSESSMENT
1. Determine the following:
The type of ostomy and its placement on
the abdomen.
The type and size of appliance currently
used and the special barrier applied to
the skin.
2. Review stoma considerations for color, size
and shape, bleeding tendencies and healing
status per client’s record prior to seeing the
client.
PLANNING
1. Prepare equipment and supplies.
2. Identify the patient and explain the
procedure to be performed.
IMPLEMENTATION
1. Close room curtains or door. If ambulatory,
patient may be assisted to reach the bathroom
in doing the whole procedure.
2. Wash hands and don gloves.
3. Help the patient assume a position of choice –
supine, side-lying or standing position
depending on the client’s mobility status.
3. Unfasten the belt if the client is wearing one.
4. Remove old colostomy pouch and wipe off
fecal residues with a damp washcloth while
completely assessing the stoma and peristomal
skin integrity. (Sometimes the skin barrier may
be left in placed if colostomy pouch is with a
detachable faceplate.)
5. Place a piece of tissue or gauze over the stoma,
and change it as needed.
6. For easy and quick succession of procedure,
prepare ahead of time the skin barrier
(peristomal seal):
Use the guide to measure and cut for the
size of skin barrier opening by putting it
slightly on top of the actual stomal
opening.
On the backing of the skin barrier, trace a
circle the same size as the stomal
opening
Cut out the traced stoma pattern to make an
opening in the skin barrier and place it on
the bedside in the meantime.
7. Wash skin gently with skin cleanser or
washcloth soaked in mild soap and water.
Remove all secretions from the skin using a
gauze, toilet tissue or washcloth.
8. Rinse soap thoroughly. Blot dry.
9. If blood appears when washing, reassure the
client that small amount is normal. Continuous
bleeding is abnormal after the pouch is in place.
10. Observe conditions of skin, stoma, sutures;
encourage patient to make observations at
home (e.g. skin feels irritated.)
11. Skin must be absolutely dry. Make use of
paper on pat skin or hair dryer set on cool to
assist in drying.
12. Have the colostomy pouch ready by
removing backing from a barrier. Apply pouch
to the skin after cleaning and drying skin.
Smooth out from the outer. Hold in place firmly
for 1-3 minutes.
13. Apply hypoallergenic tape as needed to
edges of faceplate over skin barrier. Some
pouches are manufactured with tape in place.
Use of tape may be optimal.
14. Fold bottom, edges of the pouch over to fit
clamp. Secure clamp.
15. Dispose old appliance in the appropriate
trash bin.
16. Remove gloves and do hand wash.
EVALUATION
1. Note appearance of stoma around the skin
and incision (if any) while pouch is removed
and skin is cleansed. Report any deviations
from normal findings to the physician.
DOCUMENTATION
1. Chart type of pouch and skin barrier applied
in nurse’s notes
2. Record amount and appearance of affluent in
pouch, size of stoma, color, texture, condition of
peristomal skin and sutures.
Evaluator
________________________ ________________________ ________________________
Clinical Instructor’s Name Student’s Name and Date
and Signature Signature
