Question

NASA astyka En ANCOL REVIEW MODE CHAPTER 10 E LEARNING TEMPLATE: Nursing Skill UDENT NAME SKILL NAME Administering arontinas Description of Skill ancak residual every 4 tochr. Foaching Indications CONSIDERATIONS Nursing Interventions (pre, intra, post) Outcomes/Evaluation Client Education Potential Complications Nursing Interventions

Answer 1

Description of skill

fowler's position used to promote drainage or ease breathing.Head rest is adjusted to desire height and bed is raised slightly under patient's knees.

1. mark the nasogastric tube at a point 50cm from the distal tip :call this point'A'.
2. Have the patient sit in a neutral position with head facing fowards.place the distal tip of the tubing at the tip of the patient nosea 'N'.extend the tube to tragus(tip) of the ear'E',and then extend the tube staright down to the tip of the xiphoid (X).mark the point 'B' on the tubing.
3. To locate point C on the tube .find the midpoint between points A and B.The nasogastric tube is passed to point C to ensure optimum placement in the stomach.

Indication

1. To decompress the stomach and remove gas and liquids.
2. To lavage the stomach and remove ingested toxins.
3. To administer medications and feeds.
4. As part of the management of an obstruction.
5. As part of the management of haematemesis.
6. To aspirate gastric contents for analysis.

Outcomes /Evaluation

1. Observe the patient to determine response to procedure.
2. Persistent gagging- prolonged intubation and stimulation of the gag reflex can result in vomiting and aspiration.coughing may indicate presence of tube in the airway.
3. Note the location of external site marking on the tube.
4. Documentation

• size of tube,which nostril and patients's response.
• Record length of tube from the nostril to end of tube.
• Record aspirate pH and characteristics.

Potential complication & Nursing intervention

1. clogged/Blocked tube.
2. Dumping syndrome.
3. Aspiration
4. Dehydration-diarrheo is a common problem.
5. Electrolyte imbalance:hyperkalaemia and hypernatraemia.
6. Oral mucosal breakdown.
7. Nasal irritation.

Aspiration-ensure head of bed is elevated atleast 30° while feeds are being administrated.

Most patients need supplemental free-water flushes to maintain adequate hydration; on average, they need 30 mL/kg of water per day, given either as free-water flushes or I.V. hydration.

Until recently, clinicians assumed diarrhea in patients receiving enteral feedings stemmed from malabsorption and feeding intolerance. But more recent research points to medications, especially those high in sorbitol, as the main culprit. So be sure to rule out medications as the cause of diarrhea before looking for other causes, including malabsorption and rapid delivery rates.

To reduce the risk of refeeding syndrome in patients with vitamin and mineral deficiencies, supplements may be ordered for parenteral administration before enteral feedings begin. Refer to specific guidelines based on total energy needs and specific micronutrient deficiencies; thiamine and other B-vitamin deficiencies are the most pressing ones to address before initiating enteral feeding. As the tube-feeding goal rate is achieved, taper micronutrient supplement dosages as indicate

Nursing intervention

When beginning enteral feedings, monitor the patient for feeding tolerance. Assess the abdomen by auscultating for bowel sounds and palpating for rigidity, distention, and tenderness. Know that patients who complain of fullness or nausea after a feeding starts may have higher a GRV.

On an ongoing basis, monitor patients for gastric distention, nausea, bloating, and vomiting. Stop the infusion and notify the provider if the patient experiences acute abdominal pain, abdominal rigidity, or vomiting