NGT INSERTION

DEFINITION

A nasogastric tube is a flexible plastic tube inserted

through the nostrils, down the nasopharynx, and
into the stomach or the upper portion of the small
intestine. Placement of the NG tube is always
confirmed by an X-ray prior to use.

PURPOSES

● To administer tube feedings and

medications to clients unable to eat by
mouth or swallow a sufficient diet without
aspirating food or fluids into the lungs
● To establish a means for suctioning
stomach contents to prevent gastric
distention, nausea, and vomiting
● To remove stomach contents for laboratory
analysis
● To lavage (wash) the stomach in case of
poisoning or overdose of medications

ASSESSMENT

● Check for history of nasal surgery or

deviated septum
● Assess patency of nares
● Determine presence of gag reflex
● Assess mental status or ability to participate
in the procedure

PLANNING

Before inserting a nasogastric tube, determine the

size of the tube to be inserted and whether the
tube is to be attached to a suction

EQUIPMENT

● Large – or small-bore tube (nonlatex

preferred)
● Non allergenic adhesive tape, 2.5 cm (1 in.)
● Clean gloves
● Water - soluble lubricant
● Facial tissues
● Glass of water and drinking straw
● 20 – 50 -ml syringe with an adapter
● Basin
● Ph test strip or meter
 ● Bilirubin dipstick
● Stethoscope
● Disposable pad or towel
Suction apparatus
● Safety pin and elastic band
● C02 detector (optional)

IMPLEMENTATION

1. Assist the client to a high Fowler’s position

if his or her health condition permits, and
support the head on a pillow.

2. Place a towel or disposable pad across the

chest

3. Prior to performing the insertion, introduce Identifying the patient ensures the right patient
yourself and verify the client’s identity using receives the intervention and helps prevent errors.
two patient's identifiers,(i.g., name and date
of birth.) Explain to the client what you are Explanation facilitates patient cooperation
going to do, why it is necessary, and how
he or she can participate. The passage of a
gastric tube is unpleasant because the gag
reflex is activated during insertion. Establish
a method for the client to indicate distress
and a desire for you to pause the insertion.
Raising a finger or a hand is often used for
this.

4. Perform hand hygiene and observe other Hand hygiene and PPE prevent the spread of
appropriate infection control procedures microorganisms

5. Provide for client privacy Closing the door or pulling the curtain is the client's
right to privacy

6. Assess the client’s nares

● Apply clean gloves
● Ask the client to hyperextend the head, and
using a flashlight, observe the intactness of
the tissues of the nostrils, including any
irritations or abrasions.
● Examine the nares for any obstructions or
deformities by asking the client to breathe
through one nostril while occluding the
other.
● Select the nostril that has the greater
airflow.

7. Prepare the tube

● If a small bore-tube is being used, ensure ● An improperly positioned stylet or
stylet or guidewire is secured in position. guidewire can traumatize the nasopharynx,
esophagus and stomach.

● If a large bore- tube (e.g Salem sump tube) ● This allows the tubing to become more
 is being used, place the tube in a basin of pliable and flexible. However, if the
warm water, while preparing the client softened tube becomes difficult to control, it
may be helpful to place the distal end in a
basin of ice water to help it hold its shape.

8. Determine how far to insert the tube.

● Use the tube to mark off the distance from This length approximates the distance from the
the tip of the client’s nose to the tip of the nares to the stomach. This distance varies among
earlobe to the tip of the xiphoid individuals.
● Mark this length with adhesive tape if the
tube does not have markings

9. Insert the tube

● Lubricate the tip of the tube well with water ● A water-soluble lubricant dissolves if the
soluble lubricant or water to ease insertion. tube accidentally enters the lungs. An oil-
In some agencies, topical lidocaine based lubricant, such as petroleum jelly, will
anesthetic is used on the tube or in the not dissolve and could cause respiratory
client’s nose to numb the area. complications if it enters the lungs.

● Insert the tube, with its natural curve toward ● Hyperextension of the neck reduces the
client, into the selected nostril. Ask the curvature of the nasopharyngeal junction.
client to hyperextend the neck, and gently
advance the tube toward the nasopharynx

● Direct the tube along the floor of the nostril ● Directing the tube along the floor avoids the
and toward the ear on that side projections (turbinate) along the lateral wall.

● Tears are a natural body response. Provide

● Slight pressure and a twisting motion are the client with tissues as needed.
sometimes required to pass the tube into
the nasopharynx and some client’s eyes
may water at this point ● The tube should never be forced against
. resistance because of the danger if injury
● If the tube meets resistance, withdraw it
relubricate it, and insert it in the other nostril ● Tilting the head forward facilitates passage
of the tube into the posterior pharynx and
● Once the tube reaches the oropharynx esophagus rather than into the larynx;
(throat), the client will feel the tube in the swallowing move the epiglottis over the
throat and may gag and retch. Ask the opening to the larynx.
client to tilt the head forward, and
encourage the client to tilt the head forward,
and encourage the client to drink and
swallow

● If the client gags, stop passing the tube

momentarily. Have the client rest, take a
few breaths, and take sips of water to calm
the gag reflex.
● In cooperation with the client, pass the tube
5 to 10 cm (2 to 4 in.) with each swallow,
until the indicated length is inserted.
● If the client continues to gag and the tube
does not advance with each swallow,
withdraw it slightly and inspect the throat by
 looking through the mouth
● If a CO2 detector is used, after the tube has ● The tube may be coiled in the throat, if so,
been advanced approximately 30 cm (12in), withdraw it until it is straight, and try again
draw air through the detector. Any change to insert it.
in color of the color of the detector indicates
placement of the tube in the respiratory
tract (Meyer et al 2009), Immediately
withdraw the tube and reinsert

11. Ascertain correct placement of the tube

● Aspirate stomach contents, and check the
pH, which should be acidic ● Testing pH is a reliable way to determine
location of a feeding tube. Gastric contents
are commonly pH 1 to 5; 6 or greater would
indicate the contents are from lower in the
intestinal tract or in the respiratory tract.
Some researchers suggest that a pH of
greater than 4 should be followed by further
confirmation of tube location

● Aspirate can also be tested for bilirubin.

Bilirubin levels in the lungs should be
almost zero, while levels in the stomach will
be approximately 2.5mg/dl and in the
intestine more than 10mg/dl

● Almost all nasogastric tubes are ● The stylet is sharp and could pierce the
radiopaque, and position can be confirmed tube and injure the client or cut off the tube
by x-ray. Check agency policy. If a small- end.
bore tube is used, leave the stylet or
guidewire in place until the correct position
is verified by x-ray. If the stylet has been
removed, never reinsert it while the tube is
in place
● Place a stethoscope over a client’s
epigastrium and inject 10-30 ml of air into ● This method does not guarantee tube
the tube while listening for a whooshing position
sound. Although still one of the methods
used, do not use this method as the primary
method for determining placement of the
feeding tube.
● If the signs indicate placement in the lung,
remove the tube and begin again
● If the signs do not indicate placement in the
lungs or stomach, advance the tube
5cm(2in), and repeat the tests

12. Secure the tube by taping it to the bridge of

the client’s nose.
● If the client has oily skin, wipe the nose first
with alcohol to defat skin
● Cut 7.5cm (3in) of tape, and split it
lengthwise at one end, leaving 2.5-cm (1in)
 tab in the end
● Place the tape over the bridge of the client’s ● Taping in this manner prevents the tube
nose, and bring the split ends under the from pressing against and irritating the
tubing and back up over the nose. Ensure edge of the nostril
that the tube is centrally located prior to
securing with tape to maximize air flow and
prevent irritation to the side of nares.

13. Once the correct position has been

determined, attach the tube to a suction
source of feeding apparatus as ordered , or
clamp the end of the tubing.

14. Secure the tube to the client’s gown

● Loop an elastic band around the end of the ● The tube is attached to prevent it from
tubing, and attach the elastic band to the dangling and pulling
gown with a safety pin or
● Attach a piece of adhesive tape to the tube,
and pin the tape to the gown.
● If a Salem pump is used, attach the anti- ● This prevents gastric contents from flowing
reflux valve to the vent port (if used) and into the vent lumen
position the port above the client’s waist
● Remove and discard gloves. Perform hand
hygiene

15. Document relevant information; The

insertion of the tube the means by which
correct placement was determined and
client responses (e.g. discomfort or
abdominal distention)

16. Establish a plan for providing daily

nasogastric tube care
● Inspect the nostril for discharge and
irritation
● Clean the nostril and tube with moistened,
cotton-tipped applicators
● Apply a water-soluble lubricant to the nostril
if it appears dry or encrusted
● Change the adhesive tape as required
● Give frequent mouth care. Due to the
presence of the tube, the client may
breathe through the mouth

17. If suction is applied ensure the patency of

both the nasogastric and suction tubes is
maintained
● Irrigations of the tube may be required at
regular intervals. In some agencies,
irrigations must be ordered by the primary
care provider. Prior to each irrigation,
recheck tube placement
● If a Salem sump tube is used, follow
agency policies for irrigating the vent lumen
 with air to maintain patency of the
suctioning lumen. Often, a sucking sound
can be heard from the vent port if it is
patented.
● Keep accurate records of the client’s fluid
intake and output, and record the amount
and characteristics of the drainage

18. Document the type of the tube inserted,

date and time of tube insertion, type of
suction used, color and amount of gastric
contents, and the client’s tolerance of the
procedure

EVALUATION

19. Conduct appropriate follow up, such as

degree of client comfort, client tolerance of
the nasogastric tube, correct placement of
nasogastric tube in stomach, client
understanding of restrictions, color and
amount of gastric contents if attached to
suction , or stomach contents aspirated.
 Gastric Gavage: NASOGASTRIC TUBE FEEDING

DEFINITION

Gavage (gastric) feeding is an artificial method of

giving fluids and nutrients through a tube, that has
passed into the esophagus and stomach through
the nose, mouth or through the opening made on
the abdominal wall, when oral intake is
inadequate or impossible

PURPOSES

1. When the client is unable to take food by

mouth. For example, unconscious,
semiconscious and delirious clients.
2. For a client who refuses food. E.g. client
with psychosis.
3. When the condition of the mouth or
esophagus makes swallowing difficult or
impossible. For example, fracture of the
jaw, repair of the cleft palate and cleft lips,
surgery of the mouth, throat and
esophagus, paralysis of face and throat,
stricture of the esophagus.
4. When the client is too weak to swallow
food or when the conditions make it
difficult to take a large amount of food
orally, e.g., acute and chronic infections,
severe burns, terminal malignancy,
malnutrition and prematurity.
5. When the client is unable to retain the
food, e.g. anorexia nervosa and vomiting

ASSESSMENT

● Assess the abdomen by inspecting for

presence of distention, auscultate for
bowel sounds, and palpate the abdomen
for firmness or tenderness. If the abdomen
is distended, consider measuring the
abdominal girth at the umbilicus.
● If the patient reports any tenderness or
nausea, exhibits any rigidity or firmness of
the abdomen, and if bowel sounds are
absent, confer with the primary care
provider before administering the tube
feeding. Assess for patient and/or family
understanding, if appropriate, for the
rationale for the tube feeding and address
any questions or concerns expressed by
 the patient and family members. Consult a
primary care provider, if needed, for
further explanation.

PLANNING

● Check feeding formula containers for

expiry dates. Discard expired formulas.
● Powdered formulas should be used within
24 hours of mixing.
● Shake the container well to mix the
solution thoroughly.
● The formula should be warmed to room
temperature before feeding. Administering
cold formulas can increase the chance of
diarrhea. Do not warm the formula in
direct heat or microwave as it may cause
the solution to curdle and the chemical
composition. Also, hot formula can injure
the patient.

EQUIPMENT

● Prescribed tube feeding formula at room

temperature
● Feeding bag or prefilled tube feeding set
● Stethoscope
● Nonsterile gloves
● Disposable pad or towel
● Asepto or Toomey syringe
● Enteral feeding pump (if ordered)
● Clamp (Hoffman or butterfly)
● IV pole
● Water for irrigation and hydration, as
needed pH paper
● Tape measure or other measuring device
Osterized Food

IMPLEMENTATION

1. Perform hand hygiene and put on PPE, if Hand hygiene and PPE prevent the spread of
indicated. microorganisms. PPE is required based on
transmission precautions.

2. Identify the patient by using two identifiers Identifying the patient ensures the right patient
(patient full name and date of birth) and receives the intervention and helps prevent errors.
greet him/her by name

3. Explain the procedure to the patient and Explanation facilitates patient cooperation.
why this intervention is needed. Answer
any questions as needed.

4. Close the patient’s bedside curtain or Closing curtains or door provides for patient privacy.
 door. Raise the bed to a comfortable Having the bed at the proper height prevents back
working position, usually elbow height of and muscle strain. Due to changes in the patient’s
the caregiver. Perform key abdominal condition, assessment is vital before initiating the
assessments as described above. intervention.

5. Gather equipment. Check amount, This provides for an organized approach to the task.
concentration, type, and frequency of tube Checking ensures that correct feeding will be
feeding in the patient’s medical record. administered. Outdated formulas may be
Check formula expiration date. contaminated.

6. Assemble equipment on an overbed table Organization facilitates performance of the task.

within reach.

7. Position the patient with head of bed This position minimizes possibility of aspiration into
(HOB) elevated at least 30 to 45 degrees the trachea. Patients who are considered at high risk
or as near normal position for eating as for aspiration should be assisted to at least a 45-
possible. degree position.

8. Put on gloves. Unpin the tube from the Gloves prevent contact with blood and body fluids.
patient’s gown. Verify the position of the The tube should be marked with an indelible marker
marking on the tube at the nostril. at the nostril. This marking should be assessed each
Measure length of exposed tube and time the tube is used to ensure the tube has not
compare with the documented length. become displaced. Tube length should be checked
and compared with this initial measurement, in
conjunction with pH measurement and visual
assessment of aspirate. An increase in the length of
the exposed tube may indicate dislodgement.

9. Attach a syringe to the end of the tube and The tube is in the stomach if its contents can be
aspirate a small amount of stomach aspirated: pH of aspirate can then be tested to
contents. determine gastric placement. If unable to obtain a
specimen, reposition the patient and flush the tube
with 30 mL of air. This action may be necessary
several times. Current literature recommends that
the nurse ensures proper placement of the NG tube
by relying on multiple methods and not on one
method alone.

10. Check the pH Current research demonstrates that the use of pH is

predictive of correct placement. The pH of gastric
contents is acidic (less than 5.5). If the patient is
taking an acid-inhibiting agent, the range may be 4.0
to 6.0. The pH of intestinal fluid is 7.0 or higher. The
pH of respiratory fluid is 6.0 or higher. This method
will not effectively differentiate between intestinal
fluid and pleural fluid. Testing for pH before the next
feeding in intermittent feedings is conducted since
the stomach has been emptied of the feeding
formula. However, if the patient is receiving
continuous feedings, the pH measurement is not as
useful, since the formula raises the pH.

11. Visualize aspirated contents, checking for Gastric fluid can be green, with particles, off-white,
color and consistency. or brown if old blood is present. Intestinal aspirate
tends to look clear or straw-colored to a deep golden
 yellow color. Also, intestinal aspirate may be
greenish-brown if stained with bile. Respiratory or
tracheobronchial fluid is usually off-white to tan and
may be tinged with mucus. A small amount of blood-
tinged fluid may be seen immediately after NG
insertion.

12. If it is not possible to aspirate contents; The x-ray is considered the most reliable method for
assessments to check placement are identifying the position of the NG tube.
inconclusive; the exposed tube length has
changed; or there are any other
indications that the tube is not in place,
check placement by x-ray.

13. After multiple steps have been taken to Checking for residual before each feeding or every 4
ensure that the feeding tube is located in to 6 hours during a continuous feeding according to
the stomach or small intestine, aspirate all institutional policy is implemented to identify delayed
gastric contents with the syringe and gastric emptying. High gastric residual volumes
measure to check for gastric residual—the (200 to 250 mL or greater) can be associated with
amount of feeding remaining in the high risk for aspiration and aspiration-related
stomach. Return the residual based on pneumonia. Some experts now recommend that the
facility policy. Proceed with feeding if patient’s pattern of residual is more important than
amount of residual does not exceed the amount. Feedings should be held if residual
agency policy or the limit indicated in the volumes exceed 200 mL on two successive
medical record. assessments (ASPEN). Research findings are
inconclusive on the benefit of returning gastric
volumes to the stomach or intestine to avoid fluid or
electrolyte imbalance, which has been accepted
practice. Consult facility policy concerning this
practice

14. Flush tube with 30 mL of water for Flushing tube prevents occlusion. Capping the tube
irrigation. Disconnect syringe from tubing deters the entry of microorganisms and prevents
and cap end of tubing while preparing the leakage onto the bed linens.
formula feeding equipment. Remove
gloves.

15. Put on gloves before preparing, Gloves prevent contact with blood and body fluids
assembling, and handling any part of the and deter transmission of contaminants to feeding
feeding system. equipment and/or formula.

16. Administer feeding.

16.1 When Using a Feeding Bag (Open
System):
16.1.1 Label bag and/or tubing with date Labeling date and time of first use allows for
and time. Hang the bag on an IV pole and disposal within 24 hours, to deter growth of
adjust to about 12 inches above the microorganisms. Proper feeding bag height reduces
stomach. Clamp tubing. risk of formula being introduced too quickly.

16.1.2 Check the expiration date of the Cleansing container top with alcohol minimizes risk
formula. Cleanse the top of the feeding for contaminants entering the feeding bag. Formula
container with a disinfectant before displaces air in tubing.
opening it. Pour formula into the feeding
bag and allow the solution to run through
tubing. Close clamp.
 16.1.3 Attach feeding setup to feeding Introducing formula at a slow, regular rate allows the
tube, open clamp, and regulate drip stomach to accommodate the feeding and
according to the medical order, or allow decreases GI distress.
feeding to run in over 30 minutes.

16.1.4 Add 30 to 60 mL (1 to 2 oz.) of Water rinses the feeding from the tube and helps to
water for irrigation to feeding bag when keep it patent
feeding is almost completed and allow it to
run through the tube.

16.1.5 Clamp tubing immediately after Clamping the tube prevents air from entering the
water has been instilled. Disconnect stomach. Capping the tube deters entry of
feeding setup from feeding tube. Clamp microorganisms and covering end of tube protects
tube and cover end with cap. patient and linens from fluid leakage from tube.

16.2 When Using a Large Syringe (Open

System):
16.2.1 Remove plunger from 30- or 60- Introducing the formula at a slow, regular rate allows
mL syringe. the stomach to accommodate the feeding and
decreases GI distress.

16.2.2 Attach syringe to feeding tube, The higher the syringe is held, the faster the formula
pour pre measured amount of tube flows.
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 a syringe
plunger.

16.2.3 Add 30 to 60 mL (1 to 2 oz.) of Water rinses the feeding from the tube and helps to
water for irrigation to the syringe when keep it patent.
feeding is almost completed, and allow it
to run through the tube.

16.2.4 When the syringe has emptied, By holding syringe high, the formula will not
hold the syringe high and disconnect it backflow out of tube and onto patient. Clamping the
from the tube. Clamp tube and cover end tube prevents air from entering the stomach.
with cap. Capping end of tube deters entry of microorganisms.
Covering the end protects the patient and linens
from fluid leakage from the tube.

16.3 When Using an Enteral Feeding Closing clamp prevents formula from moving
Pump: through tubing until nurse is ready. Labeling date
16.3.1 Close flow-regulator clamp on and time of first use allows for disposal within 24
tubing and fill feeding bag with prescribed hours, to deter growth of microorganisms.
formula. Amount used depends on agency
policy. Place a label on the container with
the patient's name, date, and time the
feeding was hung.

16.3.2 Hang feeding container on IV pole. This prevents air from being forced into the stomach
Allow the solution to flow through tubing. or intestines.

16.3.3 Connect to the feeding pump Feeding pumps vary. Some of the newer pumps
following manufacturer’s directions. Set have built-in safeguards that protect the patient from
 rate. Maintain the patient in the upright complications. Safety features include cassettes that
position throughout the feeding. If the prevent free-flow of formula, automatic tube flush,
patient needs to lie flat temporarily, pause safety tips that prevent accidental attachment to an
the feeding. Resume the feeding after the IV setup, and various audible and visible alarms.
patient’s position has been changed back Feedings are started at full strength rather than
to at least 30 to 45 degrees. diluted, which was recommended previously. A
smaller volume, 10 to 40 mL, of feeding infused per
hour and gradually increased has been shown to be
more easily tolerated by patients.

17. Observe the patient’s response during and Pain or nausea may indicate stomach distention,
after tube feeding and assess the which may lead to vomiting. Physical signs, such as
abdomen at least once a shift. abdominal distention and firmness or regurgitation of
tube feeding, may indicate intolerance.

18. Have the patient remain in an upright This position minimizes risk for backflow and
position for at least 1 hour after feeding. discourages aspiration, if any reflux or vomiting
should occur.

19. Remove equipment and return the patient Promotes patient comfort and safety. Removing
to a position of comfort. Remove gloves. gloves properly reduces the risk for infection
Raise the side rail and lower bed. transmission and contamination of other items.

20. Put on gloves. Wash and clean equipment This prevents contamination and deters spread of
or replace according to agency policy. microorganisms. Reusable systems are cleansed
Remove gloves. with soap and water with each use and replaced
every 24 hours.

21. Remove additional PPE, if used. Perform Removing PPE properly reduces the risk for
hand hygiene infection transmission and contamination of other
items. Hand hygiene prevents transmission of
microorganisms.

EVALUATION

1. Patients receive the ordered tube feeding

without complaints of nausea, episodes of
vomiting, gastric distension, or diarrhea.
2. Patients demonstrate an increase in
weight.
3. Patient emains free from any signs and
symptoms of aspiration
4. Patient voices knowledge related to tube
feeding.
 GASTRIC LAVAGE

DEFINITION

Gastric lavage is the aspiration of the stomach

contents and washing out of the stomach by means
of a gastric tube.

PURPOSES

1. To remove unabsorbed poison after poison

ingestion

2. To diagnose gastric hemorrhage and for the

arrest of hemorrhage

3. To cleanse the stomach before endoscopic

procedures

4. To remove liquid or small particles of

material from the stomach

ASSESSMENT

● Assess abdomen by inspecting for

presence of distention, auscultating for
bowel sounds, and palpating the abdomen
for firmness or tenderness. If the abdomen
is distended, consider measuring the
abdominal girth at the umbilicus. If the
patient reports any tenderness or nausea,
or exhibits any rigidity or firmness of the
abdomen, confer with the primary care
provider.
● If the NGT is attached to suction, assess
suction to ensure that it is running at the
prescribed pressure.
● Inspect drainage from NGT, including color,
consistency, and amount.

PLANNING

EQUIPMENT

● NGT connected to continuous or

intermittent suction
 ● Stethoscope
● Water or normal saline solution for
irrigation (based on facility policy)
● Non-sterile gloves
● Additional PPE, as indicated
● Irrigation set (or a 60-mL catheter-tip
syringe and cup for irrigating solution)
● Clamp
● Disposable waterproof pad or bath towel
● Emesis basin
● Tape measure (as needed for
measurement of abdominal girth)
● pH paper and measurement scale (
optional)

IMPLEMENTATION

1. Perform hand hygiene and put on PPE, if Hand hygiene and PPE prevent the spread of
indicated. microorganisms. PPE is required based on
transmission precautions.

2. Identify the patient using two identifiers. Identifying the patient ensures the right patient
receives the intervention and helps prevent errors.

3. Explain the procedure to the patient and Explanation facilitates patient cooperation.
why this intervention is needed. Answer any
questions, as needed.

4. Pull the patient’s bedside curtain. Raise bed Provide for privacy. Appropriate working height
to a comfortable working position, usually facilitates comfort and proper body mechanics for
elbow height of the caregiver. Assist the nurse. This position minimizes risk for
patient to 30- to 45-degree position, unless aspiration. Preparing the irrigation provides for an
this is contraindicated. Pour the irrigating organized approach to the task.
solution into the container.

5. Gather equipment. Verify the medical order Assembling equipment provides for an organized
or facility policy and procedure regarding approach to the task. Verification ensures the
frequency of irrigation, solution type, and patient receives the correct intervention. Facility
amount of irrigant. Check expiration dates policy dictates safe intervals for reuse of
on irrigating solutions and irrigation sets. equipment.

6. Assemble equipment on an overbed table Organization facilitates performance of the task.

within reach.

7. Put on gloves. Place a waterproof pad on Gloves prevent contact with body fluids.
the patient’s chest, under the nasogastric Waterproof pad protects the patient's clothing and
tube and suction tubing. bed linens from accidental leakage of gastric fluid.

8. Check placement of the NG tube. Checking placement before the instillation of fluid is
Auscultation of air insufflated through the necessary to prevent accidental instillation into the
feeding tube ('whoosh' test). respiratory tract if the tube has become dislodged.

8.1 Attach a syringe to the end of the tube The tube is in the stomach if its contents can be
and aspirate a small amount of stomach aspirated: pH of aspirate can then be tested to
 contents. determine gastric placement. If unable to obtain a
specimen, reposition the patient and flush the tube
with 30 mL of air. This action may be necessary
several times. Current literature recommends that
the nurse ensures proper placement of the NG
tube by relying on multiple methods and not on one
method alone.

8.2 Check the pH Current research demonstrates that the use of pH

is predictive of correct placement. The pH of
gastric contents is acidic (less than 5.5). If the
patient is taking an acid-inhibiting agent, the range
may be 4.0 to 6.0. The pH of intestinal fluid is 7.0
or higher. The pH of respiratory fluid is 6.0 or
higher. This method will not effectively differentiate
between intestinal fluid and pleural fluid. Testing for
pH before the next feeding in intermittent feedings
is conducted since the stomach has been emptied
of the feeding formula. However, if the patient is
receiving continuous feedings, the pH
measurement is not as useful, since the formula
raises the pH.

8.3 Visualize aspirated contents, checking Gastric fluid can be green, with particles, off-white,
for color and consistency. or brown if old blood is present. Intestinal aspirate
tends to look clear or straw-colored to a deep
golden yellow color. Also, intestinal aspirate may
be greenish-brown if stained with bile. Respiratory
or tracheobronchial fluid is usually off-white to tan
and may be tinged with mucus. A small amount of
blood-tinged fluid may be seen immediately after
NG insertion.

8.4 If it is not possible to aspirate contents; The x-ray is considered the most reliable method
assessments to check placement are for identifying the position of the NG tube.
inconclusive; the exposed tube length has
changed; or there are any other indications
that the tube is not in place, check
placement by x-ray.

9. Draw up 30 mL of irrigation solution (or This delivers a measured amount of irrigant

amount indicated in the order or policy) into through the tube. Saline solution (isotonic) may be
a syringe. used to compensate for electrolytes lost through
nasogastric drainage.

10. Place the tip of the syringe in the tube. Hold Gentle insertion of saline solution (or gravity
the syringe upright and gently insert the insertion) is less traumatic to gastric mucosa.
irrigant (or allow solution to flow in by
gravity if facility policy or medical order
indicates). Do not force the solution into the
tube.

11. If unable to irrigate the tube, reposition the Tube may be positioned against gastric mucosa,
patient and attempt irrigation again. Inject making it difficult to irrigate. Injection of air may
10 to 20 mL of air and aspirate again. If reposition the end of the tube.
 repeated attempts to irrigate a tube fail,
consult with a physician.

12. After the irrigant has been installed, hold Return flow may be collected in an irrigating tray or
the end of NGT over the irrigation tray or other available container and measured. This
emesis basin. Observe the return flow of amount will need to be subtracted from the irrigant
NG drainage into available containers. to record the true NG drainage. A second method
involves subtracting the total irrigant from the shift
from the total NG drainage emptied over the entire
shift, to find the true NG drainage. Check agency
policy for guidelines.

13. Remove gloves. Lower the bed and raise Lowering the bed and assisting the patient to a
side rails, as necessary. Assist the comfortable position promotes safety and comfort.
patient to a position of comfort. Perform
hand hygiene.

14. Put on gloves. Measure returned solution, if Gloves prevent contact with blood and body fluids.
collected outside of suction apparatus. Irrigant placed in the tube is considered intake;
Rinse equipment if it will be reused. Label solution returned is recorded as output. Record on
with the date, patient’s name, room number, the intake and output record. Rinsing promotes
and purpose (for NGT/ irrigation). cleanliness, infection control, and prepares
equipment for next irrigation.

15. Remove gloves and additional PPE, if Removing PPE properly reduces the risk for
used. Perform hand hygiene. infection transmission and contamination of other
items. Hand hygiene prevents transmission of
microorganisms.

EVALUATION

1. Patient demonstrates a patent and

functioning NGT.
2. Patient reports no distress with the
irrigation.
3. Patient remains free of any signs and
symptoms of injury or trauma.

BLOOD TRANSFUSION

DEFINITION

A blood transfusion is the infusion of whole blood or a

blood component such as plasma, red blood cells,
cryoprecipitate, or platelets into the patient’s venous
circulation.
PURPOSES

A blood product transfusion is given when a patient’s

red blood cells, platelets, or coagulation factors
decrease to levels that compromise a patient’s health.

ASSESSMENT

1. Obtain a baseline assessment of the patient,

including vital signs, heart and lung sounds, and
urinary output.
2. Review the most recent laboratory values, in
particular, the complete blood count (CBC).
3. Ask the patient about any previous transfusions,
including the number he or she has had and any
reactions experienced during a transfusion.
4. Inspect the IV insertion site, noting the gauge of
the IV catheter. Blood or blood components may
be transfused via a 14- to 24-gauge peripheral
venous access device. Transfusion for neonate
or pediatric patients is usually given using a 22-
to 24-gauge peripheral venous access device
(INS, 2011).

PLANNING

EQUIPMENT

● Blood productImage result for iv pole for blood

transfusion
● Blood administration set (tubing with in-line filter,
or add-on filter, and Y for saline
administration)Image result for iv pole for blood
transfusion equipments
● 9% normal saline for IV infusion
● IV pole
● Venous access; if peripheral site, preferably
initiated with a 20-gauge catheter or larger
● Alcohol or other disinfectant wipes
● Clean gloves
● Additional PPE, as indicated
● Tape (hypoallergenic)
● Second registered nurse (or other licensed
practitioner; e.g., a physician) to verify blood
product and patient information

IMPLEMENTATION

1. Verify the medical order for transfusion of a Verification of order ensures the right patient
blood product. Verify the completion of informed receives the correct intervention.
 consent documentation in the medical record. Premedication is sometimes administered to
Verify any medical order for pretransfusion decrease the risk for allergic and febrile
medication. If ordered, administer medication at reactions for patients who have received
least 30 minutes before initiating transfusion. multiple previous transfusions.

2. Gather all equipment. Preparation promotes efficient time

management and an organized approach to
the task.

3. Perform hand hygiene and put on PPE, if Hand hygiene and PPE prevent the spread of
indicated. microorganisms. PPE is required based on
transmission precautions.

4. Verify patient using 2 identifiers —such as a Identifying the patient ensures the right patient
patient's full name, date of birth and/or medical receives the intervention and helps prevent
identification (ID) number—be used for every errors.
patient encounter.

5. Close the curtains around the bed and close the This ensures the patient’s privacy. Explanation
door to the room, if possible. Explain what you relieves anxiety and facilitates cooperation.
are going to do and why you are going to do it to Previous reactions may increase the risk for
the patient. Ask the patient about previous reaction to this transfusion. Any reaction to the
experience with a transfusion and any reactions. transfusion necessitates stopping the
Advise the patient to report any chills, itching, transfusion immediately and evaluating the
rash, or unusual symptoms. situation.

6. Prime blood administration set with the normal Normal saline is the solution of choice for
saline IV fluid. blood product administration. Solutions with
dextrose may lead to clumping of red blood
cells and hemolysis.

7. Put on gloves. If a patient does not have a Gloves prevent contact with blood and body
venous access in place, initiate peripheral fluids. Infusion of fluid via venous access
venous access. Connect the administration set maintains patency until the blood product is
to the venous access device via the extension administered. Start an IV before obtaining the
tubing. Infuse the normal saline per facility blood product in case the initiation takes
policy. longer than 30 minutes. Blood must be stored
at a carefully controlled temperature (4°C) and
transfusion must begin within 30 minutes of
release from the blood bank.

8. Obtain blood product from blood bank according Bar codes on blood products are currently
to agency policy. Scan for bar codes on blood being implemented in some agencies to
products if required. identify, track, and assign data to transfusions
as an additional safety measure.

9. Two nurses compare and validate the following Most states/agencies require two registered
information with the medical record, patient nurses to verify the following information: unit
identification band, and the label of the blood numbers match; ABO group and Rh type are
product: the same; expiration date (after 35 days, red
blood cells begin to deteriorate). Blood is
9.1 Medical order for transfusion of blood never administered to a patient without an
product identification band. If clots or signs of
contamination (clumping, gas bubbles) are
9.2 Informed consent present, return blood to the blood bank.
 9.3 Patient identification numberImage result
for blood bag label

9.4 Patient name

9.5 Blood group and type

9.6 Expiration date

9.7 Inspection of blood product for clots,

clumping, gas bubbles

10. Obtain baseline set of vital signs before Any change in vital signs during the
beginning the transfusion. transfusion may indicate a reaction.

11. Put on gloves. If using an electronic infusion Gloves prevent contact with blood and body
device, put the device on “hold.” Close the roller fluids. Stopping the infusion prevents blood
clamp closest to the drip chamber on the saline from infusing to the patient before completion
side of the administration set. Close the roller of preparations. Closing the clamp to saline
clamp on the administration set below the allows blood product to be infused via
infusion device. Alternately, if infusing via electronic infusion device.
gravity, close the roller clamp on the
administration set.

12. Close the roller clamp closest to the drip Filling the drip chamber prevents air from
chamber on the blood product side of the entering the administration set. The filter in the
administration set. Remove the protective cap blood administration set removes particulate
from the access port on the blood container. material formed during storage of blood. If the
Remove the cap from the access spike on the administration set becomes contaminated, the
administration set. Using a pushing and twisting entire set would have to be discarded and
motion, insert the spike into the access port on replaced.
the blood container, taking care not to
contaminate the spike. Hang the blood container
on the IV pole. Open the roller clamp on the
blood side of the administration set. Squeeze
drip chamber until the in-line filter is saturated.
Remove gloves.

13. Start administration slowly (no more than 25 to

50 mL for the first 15 minutes). Stay with the
patient for the first 5 to 15 minutes of
transfusion. Open the roller clamp on the
administration set below the infusion device. Set
the flow rate and begin the transfusion.
Alternately, start the flow of solution by releasing
the clamp on the tubing and counting the drops.
Adjust until the correct drop rate is achieved.
Assess the flow of the blood and function of the
infusion device. Inspect the insertion site for
signs of infiltration.

14. Observe the patient for flushing, dyspnea, These signs and symptoms may be an early
 itching, hives or rash, or any unusual comments. indication of a transfusion reaction.

15. After the observation period (5 to 15 minutes) If no adverse effects occurred during this time,
increase the infusion rate to the calculated rate the infusion rate is increased. If complications
to complete the infusion within the prescribed occur, they can be observed and the
time frame, no more than 4 hours. transfusion can be stopped immediately.
Verifying the rate and device settings ensures
the patient receives the correct volume of
solution. Transfusion must be completed
within 4 hours due to potential for bacterial
growth in blood product at room temperature.

16. Reassess vital signs after 15 minutes. Obtain Vital signs must be assessed as part of
vital signs thereafter according to facility policy monitoring for possible adverse reaction.
and nursing assessment. Facility policy and nursing judgment will
dictate frequency.

17. Maintain the prescribed flow rate as ordered or Rate must be carefully controlled, and the
as deemed appropriate based on the patient’s patient’s reaction must be monitored
overall condition, keeping in mind the outer frequently.
limits for safe administration. Ongoing
monitoring is crucial throughout the entire
duration of the blood transfusion for early
identification of any adverse reactions.

18. During transfusion, assess frequently for If a transfusion reaction is suspected, the
transfusion reaction. Stop blood transfusion if blood must be stopped. Do not infuse the
you suspect a reaction. Quickly replace the normal saline through the blood tubing
blood tubing with a new administration set because you would be allowing more of the
primed with normal saline for IV infusion. Initiate blood into the patient’s body, which could
an infusion of normal saline for IV at an open complicate a reaction. Besides a serious life-
rate, usually 40 mL/hour. Obtain vital signs. threatening blood transfusion reaction, the
Notify primary care providers and blood banks. potential for fluid–volume overload exists in
older patients and patients with decreased
cardiac function.

19. When transfusion is complete, close the roller Saline prevents hemolysis of red blood cells
clamp on the blood side of the administration set and clears the remainder of blood in the IV
and open the roller clamp on the normal saline line.
side of the administration set. Initiate infusion of
normal saline. When all of the blood has infused Proper disposal of equipment reduces
into the patient, clamp the administration set. transmission of microorganisms and potential
Obtain vital signs. Put on gloves. Cap access contact with blood and body fluids.
site or resume previous IV infusion. Dispose of
blood- transfusion equipment or return to blood
bank, according to facility policy.

20. Remove equipment. Ensure patient’s comfort. Promotes patient comfort and safety.
Remove gloves. Lower bed, if not in lowest Removing gloves properly reduces the risk for
position. infection transmission and contamination of
other items.

21. Remove additional PPE, if used. Perform Removing PPE properly reduces the risk for
hand hygiene. infection transmission and contamination of
other items. Hand hygiene prevents
 transmission of microorganisms.

22. Monitor and assess the patient for one hour Ensures early detection and prompt
after the transfusion for signs and symptoms of intervention. Delayed transfusion reactions
delayed transfusion reaction. Provide patient can occur one to several days after
education about signs and symptoms of delayed transfusion.
transfusion reactions.

23. Complete all documentation as required by Documentation may include:

agency. ● Transfusion record form
● All vital signs and reactions
● Any significant findings, initiation and
termination of transfusion
● Record of transfusion on the in-and-out
sheet

EVALUATION

1. Patient receives the blood transfusion without

any evidence of a transfusion reaction or
complication.
2. Patient exhibits signs and symptoms of fluid
balance, improved cardiac output, and
enhanced peripheral tissue perfusion.
3. The venous access device remains patent.

Conditions and Disorders needing Blood Transfusion

● Anemia
● Hemophilia
● Sickle Cell Disease
● Kidney Disease
● Liver Disease

Types of Blood Transfusions

1. Packed Red Blood Cells
● Used to replace erythrocytes
● Infusion time: 2 to 4hrs.
● Each unit increases the hemoglobin level by 1 g/dl and hematocrit by 3%.
● The change in laboratory values takes 4 to 6 hours after completion of blood
transfusion.

2. Platelets
● Used to treat thrombocytopenia and platelet dysfunctions.
● Infusion time: 15 to 30 minutes
● Crossmatching is not required.
● An increase of 5000-10,000 cells/mm3 is expected for each unit of platelets
administered after 18-24 hours transfusion
3. Fresh Frozen Plasma
● Used to treat thrombocytopenia and platelet dysfunctions.
 ● Infusion time: 15 to 30 minutes
● Crossmatching is not required.
● An increase of 5000-10,000 cells/mm3 is expected for each unit of platelets
administered after 18-24 hours transfusion
4. Cryoprecipitate
● Prepared from fresh-frozen plasma.
● Can be stored for 1 year.
● Once thawed, the product must be used.
● Infusion time: 15-30 minutes
● Used to replace factor VII and fibrinogen
5. Granulocytes
● Used to treat a client with sepsis or a neutropenic client with an infection that
is unresponsive to antibiotics.
● Assessed by monitoring the white blood cell and differential counts.

Compatibility
● To determine compatibility, crossmatching is done.
● The universal RBC donor is O(-); the universal recipient is AB(+).
● Client with Rh(+) blood can receive Rh(-) donor if necessary
● RH(-) should not receive Rh(+)
● Type A: can receive from type A or O
● Type B: can receive from type B or OT
● Type AB: can receive from type A, B, AB or O
● Type O: only from type O

Complications
1. Transfusion reactions
An adverse reaction that happens as a result of receiving a blood transfusion.
TYPES:
● Hemolytic
● Allergic,
● Febrile,
● Bacterial
2. Circulatory overload
3. Septicemia
4. Iron Overload
5. Disease Transmission
6. Hypocalcemia
7. Hyperkalemia
8. Citrate toxicity

Precautions and Nursing Responsibilities

● No solutions other than normal saline should be added to blood components.
● Medications are never added to blood components or piggybacked into a blood
transfusion.
● To avoid septicemia, infusions of 1 unit should not exceed the prescribed time for
administration.
 ● The blood transfusion set should be changed with each unit of blood or according to
hospital policy.
● Inspect the blood bag for leaks, abnormal color, clots and bubbles.
● Blood should be administerd as soon as possible ( 20-30 minutes) from its being
received from the blood bank.

INSERTING A STRAIGHT CATHETER OR INDWELLING CATHETER TO A MALE AND

FEMALE PATIENT

PLANNING:

Prepare the materials needed.

• Sterile gloves
• Sterile drapes
• Lubricant KY jelly
• Antiseptic cleansing solution
• Cotton balls
• Forceps
• Pre filled 10 cc syringe with normal saline to inflate balloon of indwelling catheter
• Catheter of correct size and type of procedure (i.e., intermittent or indwelling)
• Flashlight or gooseneck lamp
• Waterproof absorbent pad
• Trash receptacle
• Hospicare bag or urinary bag
• Micropore tape 2-3inches wide
• Specimen container (as needed)

ASSESSMENT:

1. Assess status of patient:

➔ When patient last voided
➔ Level of awareness or developmental stage
➔ Mobility and physical limitations of patient
➔ Patient’s sex and age
➔ Distended bladder
➔ Any pathological conditions and allergies
 IMPLEMENTATION

CRITERIA RATIONALE

[Link] your hands. Wear gloves and follow standard Washing your hands and taking standard
precautions if contact with blood or body fluids cannot precautions prevent the spread of infections.
be avoided. (Carter, 2012)

2. Identify the person using two identifiers (age and Identifying the person ensures that the procedure is
date of birth), and greet him or her by name. being done on the correct patient or resident.
Greeting the person by name is being courteous.
(Carter, 2012)

3. Explain the procedure and encourage the person Helps the person know what to expect and helps him
to participate as appropriate. understand how he can help. (Carter, 2012)

4. Provide privacy by showing any visitor where they Asking visitors to leave the room, and closing the
should wait, if necessary, until you have completed door and curtain protect the person’s right to privacy.
the procedure. Close the door and the curtain. (Carter, 2012)

5. Facing the patient, stand on the left side of bed if

right handed. Clear the bedside table and arrange
equipment.

6. Place the side rail on the opposite side of the bed. Successful catheter insertion requires a nurse to
assume a comfortable position with all equipment
easily accessible. (Perry, 2013)

7. Place a waterproof pad under the patient.

8. Position client. Assist to supine position with thighs

slightly abducted

9. Drape patient. Drape the upper trunk with a bath This promotes client’s safety. (Perry, 2013)
blanket and cover lower extremities with bed sheets
exposing only genitalia.

10. When inserting an indwelling catheter, open the Prevents soiling of bed linen. (Perry, 2013)
package containing the drainage system. Place the
drainage bag over the edge of the bottom bed frame.
Bring drainage tube up between side rail and
mattress.

11. Open catheterization kit according to directions, This position relaxes abdominal and perineal
using aseptic technique. Place the waste receptacle muscles. (Smith, 2011)
in an accessible place.

12. Don sterile gloves. This avoids unnecessary exposure of body parts
and maintains client’s comfort. (Perry, 2013)

This facilitates connection of the catheter to the

13. Organize supplies on sterile field: drainage system and provides for easy access.
13.1 Open sterile package containing catheter; pour (Taylor, 2014)
sterile package of antiseptic solution in correct
compartment containing sterile cotton balls
13.2 Lubricate tip of catheter, remove specimen
container and pre-filled syringe from collection
compartment of tray and set them aside of sterile
field.

14. Nurses may want to ensure that an inflatable Placement of equipment near the work site
balloon of indwelling catheter is intact by inserting increases efficiency. Sterile technique protects the
syringe tip through valve of intake lumen and injecting patient and prevents the spread of microorganisms.
sterile fluid until balloon inflates. Then aspirate all fluid (Taylor, 2014)
out of the inflated lumen.

15. Apply sterile drape. Apply drape over thighs just This allows nurses to handle sterile supplies without
below penis. Pick up fenestrated sterile drape, allow contamination. (Perry, 2013)
it to unfold, and drape it over penis with a fenestrated
slit resting over penis.

[Link] sterile tray and contents on sterile drape

between thighs.

[Link] that the catheter tip is properly It is necessary to open all supplies and prepare for
lubricated. Male 12.5-17.5 cm (5-7 inches). the procedure while both hands are sterile. (Taylor,
2014)

This eases insertion of the catheter through the

Cleanse urethral meatus. urethral canal. (Perry, 2013)
18.1 If the patient is not circumcised, retract foreskin
with a nondominant hand. Grasp penis at shaft just
below glans. Retract urethral meatus between thumb
and forefinger. Maintain a nondominant hand in this
position throughout the procedure.
18.2 With dominant hand, pick up a cotton ball with
forceps and clean penis. Move it in circular motion
from meatus down to the base of glans. Repeat
cleansing two more times using clean cotton balls
each time.

19. Pickup catheter with gloved dominant hand 7.5- This checks the integrity of the balloon. Do not use
10 cm (3-4 inches) from catheter tip. Hold end of the catheter if the balloon does not inflate or leaks.
catheter loosely coiled in palm of dominant hand. Checking the balloon in this way may stretch the
Place distal end of catheter in urine tray specimen. balloon and cause increased trauma on insertion.
(Perry, 2013)

20. Insert catheter

The drape expands the sterile field and protects
20.1 Lift penis to position perpendicular to the client's against contamination. Use of fenestrated drape
body and apply slight traction. may limit visualization and is considered optional by
some practitioners. (Taylor, 2014)

20.2 Ask the patient to bear down as if to void and This provides easy access to supplies during
slowly insert a catheter through the meatus. catheter insertion. (Perry, 2013)

20.3 Advance catheter 17.5-22.5 cm (7-9 inches) in This eases insertion of the catheter through the
adults and 5- 7.5 cm (2-3 inches) in young children urethral canal. (Perry, 2013)
or until urine flows out of the catheter's end. If
resistance is felt, withdraw the catheter and do not
force it through urethra. When urine appears,
advance the catheter another 5 cm (2 inches).

20.4 Lower penis and hold catheter securely in The hand touching the penis becomes
nondominant hand. Place the end of the catheter in contaminated. Cleansing the area around the
the urine tray receptacle. meatus and under the foreskin in the uncircumcised
male patient helps prevent infection. (Taylor, 2014)

For Female Patient

21. Cleanse urethral meatus

21.1 With a nondominant hand, carefully retract the Moving from the meatus toward the base of the
labia to fully expose urethra meatus. Maintain position penis prevents bringing organisms to meatus.
of nondominant hand throughout the procedure (Taylor, 2014)

21.2 With dominant hand, pick up a cotton ball with

forceps and clean the perineal by wiping from front to
back or from clitoris towards anus. Use a new cotton
ball for each wipe along the near labial fold, directly
over meatus and along the labial fold.

22. Pick up catheter with gloved dominant hand 7.5- Hold catheter near tip because it allows
10 cm (3-4 inches) from catheter tip. Hold the end of easier manipulation during insertion into
the catheter loosely coiled in the palm of the dominant urethral meatus and prevents distal end
hand. Place distal end of catheter in urine tray from striking contaminated surface.
specimen.

23. Insert catheter This movement straightens the urethra for easier
23.1 Ask patient to bear down as if to void and slowly insertion of catheter. (Smith, 2011) Bearing down
insert catheter through meatus. eases the passage of the catheter through the
urethra. (Taylor, 2014)
Deep breaths or slight twisting of the catheter bay
23.2 Advance catheter 5-7.5 cm (2-3 inches) in adults ease the catheter past resistance at sphincters.
and 2.5 cm (1 inch) in young child or until urine flows Advancing an indwelling catheter facilitates inflation
out of the catheter's end. When urine appears, of the balloon without damaging the urethra. (Taylor,
advance the catheter up to another 5cm (2 inches). 2014)
Do not force against resistance.

23.3 Release labia and hold the catheter securely This allows sterile specimen to be obtained for
with a nondominant hand. culture analysis. (Perry, 2013)
24. Collect urine specimen as needed: fill specimen This allows sterile specimen to be obtained for
cup to desired level (20-30 mL) by holding the end of culture analysis. (Perry, 2013)
catheter with the dominant hand over the cup. With
dominant hand, pinch catheter to stop urine flow
temporarily. Release catheter to allow remaining
urine in bladder to drain in the collection tray. Cover
the specimen cup and set aside for labeling.
25. Allow bladder to empty full (750-1000 mL) unless Retained urine may serve as reservoir for growth of
institution policy restricts maximal volume of urine to microorganisms. (Perry, 2013)
drain with each catheterization.
25.1 For straight, single use catheter, pinch catheter This causes less discomfort to the patient. (Taylor,
and remove slowly but smoothly when urine ceases 2014)
to flow.
25.2 For indwelling catheter, inflate balloon of the The balloon anchors the catheter in place in the
indwelling catheter. bladder. Sterile water is used to inflate the balloon
as a precaution in case the balloon ruptures. (Taylor,
2014)
25.3 While holding catheter with your thumb and little
finger of the nondominant hand at meatus, take end
of catheter and place it between first two fingers of
nondominant hand.
25.4 With free dominant hand, attach syringe to
injection port at the end of catheter.
25.5 Slowly inject total amount of solution. If client
complains of sudden pain, aspirate back solution and
advance catheter further.
25.6 After inflating the balloon fully, release catheter Improper inflation can cause patient’s discomfort
with the nondominant hand and pull it gently if there and malpositioning of catheter. (Taylor, 2014)
is resistance.
26. Attach end of catheter to the collecting tube of To facilitate drainage of urine by gravity. Raising bag
drainage system. Drainage bag must be below level on side rail will cause backflow of urine into bladder.
of bladder. (Perry, 2013)
27. Tape catheter tubing on top of thigh or lower Closed drainage system minimizes the risk of
abdomen. Allow slack in catheter so movement does organisms being introduced into the bladder.
not create tension on catheter. (Taylor, 2014)
28. Be sure that there are no obstructions or kinks in Anchoring catheter to lower abdomen reduces
tubing. Inspect all that may lead to obstruction in the pressure on urethra at junction of penis and
flow of the urine from the catheter to the drainage bag. scrotum, thus reducing the possibility of tissue injury
at this area. (Perry, 2013)
29. Remove gloves and dispose of equipment, drapes
and urine in proper receptacle.
[Link] client to comfortable position. Wash dry
perineal area as needed.
[Link] patient on ways to lie in bed with catheter. This facilitates drainage of urine and prevents the
Side lying facing drainage system with catheter and backflow of urine. (Taylor, 2014)
tubing draped over thigh and side lying facing away
from the system, catheter and tubing extended
between legs.
32. Caution patient against pulling the catheter. It maintains comfort and security. (Perry, 2013)
33. Wash hands thoroughly. It reduces transmission of microorganisms. (Perry,
2013)

EVALUATION
1. Palpate bladder and ask if patient remains uncomfortable.
2. Determine if there is no urine leaking from catheter or tubing connections.
3. Record time of procedure, characteristics and amount of urine in drainage system.
4. Observe for signs of obstruction (e.g., decreased urine in collection bag, voiding
around the catheter, abdominal discomfort and bladder distention).

NURSING CONSIDERATIONS

1. Maintain catheter patency. Place drainage tubing properly to avoid kinking or

pinching.
2. Irrigate catheter as necessary.
3. Ensure comfort and safety. Relieve bladder spasms by administering belladonna
suppositories (if ordered). Ensure adequate fluid intake and provide perineal care.
4. Prevent infection by maintaining a closed drainage system and prevent backflow of
urine by keeping drainage system below level of bladder.
5. Empty collection bag at least 8 hours.
6. Promote acidification of the urine with acid ash diet and ascorbic acid.
7. Change catheter or drainage system only when necessary.
For children or adolescents: they may be tempted to pull or tug on the catheter. Children
and adolescents may be more active in and out of bed, so the catheter must be taped securely
to the thigh to prevent it from being pulled out.
 COLLECTING A STERILE SPECIMEN FROM AN INDWELLING CATHETER

DEFINITION
A urine specimen is collected from an indwelling catheter when a urinary tract infection is
suspected and a sterile urine specimen is needed for a urine culture and sensitivity test. The
specimen must be obtained aseptically, so as not contaminate the closed drainage system or
contaminate the specimen. A registered nurse (RN) or licensed practical nurse (LPN) may
collect the specimen from the indwelling catheter.

ASSESSMENT:

1. Determine how long the catheter has been in place.

2. Observe any discharge or encrustation around urethral meatus. Assess for complaints of
pain or [Link]-icon.

MATERIALS:

➔ 3 mL syringe with 1inch needle (21-25 gauge) for culture or 20 mL syringe with 1inch
needle (21-25 gauge) for routine urinalysis
➔ Metal clamp or rubber band
➔ Alcohol, povidone-iodine, or other disinfectant swab
➔ Specimen container: non-sterile for routine urinalysis, sterile for culture
➔ Specimen label
➔ Completed laboratory requisition with patient’s name, date and time of collection
➔ Clean, disposable gloves

Implementation:

Criteria Rationale

1. Wash your hands. Wear gloves and follow Washing your hands and taking standard precautions
standard precautions if contact with blood or body prevent the spread of infections. (Carter, 2012)
fluids cannot be avoided.

2. Identify the person, and greet him or her by Identifying the person ensures that the procedure is
name. being done on the correct patient or resident. Greeting
the person by name is being courteous. (Carter, 2012)

3. Explain the procedure and encourage the Helps the person know what to expect and helps him
person to participate as appropriate. understand how he can help. (Carter, 2012)
4. Provide privacy by showing any visitor where Asking visitors to leave the room, and closing the door
they should wait, if necessary, until you have and curtain protects the person’s right to privacy.
completed the procedure. Close the door and the (Carter, 2012)
curtain.

5. Clamp the drainage tubing with clamp or rubber This ensures that the urine specimen is adequate.
band for 30 minutes. (Smith, 2011)

6. Return to room and inform patient that the This promotes cooperation. (Perry, 2013)
procedure to collect specimen from the catheter
will begin.

7. Wash hands again or an alcohol and don Handwashing deters the spread of microorganisms.
gloves. Gloves protects the nurse from exposure to
microorganisms in the urine. (Taylor, 2014)

8. Cleanse entry port for needle with disinfectant This prevents the transmission of microorganisms.
swab. (Taylor, 2014)

9. Insert the needle at 30-degree angle just above This facilitates sealing of the rubber in the port following
where the catheter is attached to drainage tube or removal of the needle. This allows urine to accumulate
built-in sampling port. in the tubing. (Smith, 2011)

10. Draw urine into 30 mL syringe for culture or

draw urine into 20 mL syringe for urine urinalysis.

11. Transfer urine from syringe into specimen

container.

12. Place lid tightly on container.

13. Unclamp catheter and allow urine to flow into This facilitates drainage of urine and prevents the
drainage bag. backflow of urine. (Taylor, 2014)
14. Secure attached properly completed
identification label and laboratory requisition
specimen.

15. Send specimen to laboratory immediately or

place in specimen refrigerator.

16. Dispose of soiled supplies and wash hands. This reduces transmission of microorganisms. (Perry,
2013)

EVALUATION

1. Check laboratory report for results.

2. Record collection of specimen on nurse’s notes; note time and date, appearance and odor.
 BLOOD GLUCOSE MONITORING

● a method of assessing the concentration of glucose in the blood.

● Tests are performed rapidly and easily by using a reagent strip (e.g. Glucostix) where
a minute drop of capillary blood is obtained from the client’s digits (finger or toe),
earlobe or heel.
● On the condition where the patient has all the equipment this test can be performed at
home, office, hospitals, clinics and even when travelling.

Children and young people < 18 years old Adults ≥ 18 years of age

Preprandial blood glucose levels 4–8 mmol/L Preprandial blood glucose levels 4–7 mmol/L

Postprandial blood glucose levels of less than Postprandial blood glucose levels of less than
10 mmol/L 9 mmol/L

Essential Equipment
● Blood glucose monitor
● Test strips
● Control solution
● Single-use safety lancets
● Non-sterile gloves
● Cotton wool/low-linting gauze
● Sharps box

Implementation

PRE-PROCEDURE

Action Rationale

1. Turn the machine on and ensure the correct date To ensure accuracy in the result record and
and time patient safety (Roche Diagnostics 2013, C).
are presented on screen, and that there is adequate
battery
life. Where applicable, enter or scan operator
number, e.g.
number or bar code on name badge, as per
manufacturer’s
guidelines.
2. Check the unit of measure and ensure that it is Units of measure may change from mmol/L to
reading in mmol/L prior to each use. mg/dL, which could result in the meter user
thinking that the blood glucose level is higher than
it actually is (MHRA 2011, C).

3 Before taking the device to the patient, the

monitor and testing strips need to be checked for
the following (where applicable to the device.
Newer automated systems will self-calibrate when
turned on)

● Testing strips are in date and have not been

left exposed to air.
● The monitor and test strips have been
calibrated together.
● If a new pack of strips is required, the
monitor is recalibrated.
● Internal quality control carried out with both
high and low or level 1 and 2 solutions, in
accordance with trust and manufacturer’s
guidelines. Ensure the LOT number is
recorded, either manually or via bar code
scanning system
● Result (pass or fail) of internal quality As any device can fail under the right conditions
control is to be recorded in equipment log
book and signed. Where an automated
device is used, ensure the device is docked
in its base unit for the centrally held
electronic records to be maintained.
● The meter has previously been
decontaminated per local guidelines and is
ft for use.
● The meter service record is in date
according to local policy.
● That the screen/display is intact and the
‘screen safety check’ has been completed
in accordance with manufacturer’s
guidelines

4. Identify the patient, i.e. verbally and against their The patient should give consent to the procedure.
hospital identity band, and explain the procedure. Explanation may allay any fear or anxieties

5. Select a site that is warm, pink and free of any It is important to avoid previous punctures by
calluses, burns, cuts, scars, bruises or rashes. rotating the site lanced to avoid fngertip soreness
Avoid skin areas that have evidence of previous and reduce callus formation (WHO 2010, C).
punctures. The usual site for lancing is the palmar Fingers on the non-dominant hand and the index
surface of the distal segment of the third or fourth fnger are generally less calloused. The index fnger
finger, ideally of the non-dominant hand as they are is also potentially more sensitive to pain due to
usually less calloused. additional nerve endings. The thumb also may be
calloused and has a pulse, indicating arterial
 presence, and the distance between the skin
surface and the bone in the ffth fnger also makes
it unsuitable for puncture (WHO 2010, C). Tips and
pads of fngers should be avoided as they are
denser with nerve supply and can be more painful

PROCEDURE

6. Ask patient to sit or lie down. To ensure the patient’s safety and minimize the
risks if they feel faint when blood is taken

7. Ask the patient to wash their hands with soap and To avoid sample contamination (CDC 2013, C).
water and dry thoroughly with low-linting gauze Not washing hands can lead to a diference in the
glucose concentration, especially with fngers
exposed to fruit or a sugar-containing product

8. Wash your hands and put on gloves. To minimize the risk of cross-infection and
contamination

9. Take a single-use lancet and, if it has depth To minimize the risk of cross-infection and
settings, ensure the correct setting is used (most accidental needlestick injury. The correct depth
commonly middle one). setting will ensure patient comfort

10. Activate the single-use, auto-disabling In settings where assisted monitoring of blood
fngerstick device/ lancet or reusable device, as per glucose is performed, single-use, auto-disabling
manufacturer’s guidelines, at the chosen site, e.g. fngerstick devices should be used. Although
the side of the fnger. Ensure the site of piercing is reusable devices may be used in the patient’s own
rotated, avoiding frequent use of index fnger and environment, they should never be used for more
thumb. Other areas may be used if fnger or palm of than one person due to the risk of bloodborne
hand are unusable. The fngertip may need ‘milking’ viruses (CDC 2013, C). The side of the fnger is
from palm of hand towards fnger to gain a large less painful and easier to obtain a hanging droplet
enough droplet of blood but avoid milking the fnger of blood. Sites are rotated to avoid infection from
alone. multiple stabbings, area becoming toughened and
to reduce pain (Roche Diagnostics 2013, C).
Milking the fnger can cause tissue fuid
contamination and a false low reading (Hortensius
et al. 2011, R1b), cause haemolysis and impede
blood fow.

11. Activate safety-engineered medical device A cost-efective way to reduce the risk of
(where applicable and if not automated), dispose of needlestick injury
lancet and testing strip in a sharps container.

12. Insert testing strip into blood glucose monitor To ensure accurate results, the window on the test
and apply the frst drop of blood to the testing strip. strip needs to be adequately flled as per
Some strips are hydrophilic and are dosed/flled manufacturer’s guidelines
from the side instead of dropping blood directly onto
the strip. Ensure that the window on the test strip is
entirely covered with blood

13. Place gauze over puncture site, apply from To ensure patient safety (Wallymahmed 2007, E)
pressure and monitor for excess bleeding. and to stop the bleeding
14. Remove gloves, place in clinical waste and To prevent healthcare-associated infections and
perform hand hygiene again. spread of antimicrobial resistance (WHO 2013, C).

POST-PROCEDURE

15. Once result is obtained (see Action fgure 15), To ensure accuracy in record keeping
document and sign.

16. Where applicable, dock machine. To ensure centralized records are maintained

17. Report any unexpected results To ensure appropriate treatment and obtain
optimal blood glucose range

Prevention and Resolution

Probelem Cause Prevention Action

Inaccurate User error including: Staf training and Contact colleague to

results • inadequate meter calibration education about repeat test and, if
• failure to code correctly poor meter diabetes are essential error persists, report
maintenance in prevention of these glucose meter to
• incorrect user technique. errors (Heinemann technician and use
50% of errors are due to an inadequate 2010, Janssen and another machine.
amount of blood on the test strip, which Delanghe 2010)
can lead to a falsely low reading (Blake
and Nathan 2004). Out-of-date or
incorrectly stored test strips are other
common errors leading to lower
glucose levels.

Common Errors in Blood Glucose Monitoring

● Dropping a very small amount of blood
● Inappropriate timing ( the test is usually performed before meals and at bedtime, or
whenever hypoglycemia or hyperglycemia occurs)
● Squeezing the puncture site too hard allowing tissue fluids to mix with the sample
● Improper maintenance of glucometers (dust or blood accumulation on the digital
display)
● Make sure that the strip is appropriate to the glucometer