Nursing Procedure for Any NURSING students

Fundamental

1. Rift Valley University Asalla Campus Nursing Department Nursing Procedures

2. Vital signs are clinical measurements that indicate the state of a patient's essential bodily functions.

3. Components of Vital Signs Body Temperature: Measures the body's heat, usually taken orally, rectally, or via the ear. Pulse Rate : Indicates heart rate, measured in beats per minute (bpm), typically taken at the wrist or neck. Respiratory Rate: Counts the number of breaths taken in one minute, usually measured by observing chest movements .

4. Cont.…. Blood Pressure: Measures the force of blood against the walls of arteries, recorded as systolic over diastolic pressure (e.g., 120/80 mmHg). Oxygen Saturation: Assesses the percentage of oxygen in the blood, often measured using a pulse oximeter.

5. Interpretation of Vital Signs Normal Ranges : Body Temperature: 97°F to 99°F (36.1°C to 37.2°C) Pulse Rate: 60 to 100 bpm for adults Respiratory Rate: 12 to 20 breaths per minute for adults Blood Pressure: Generally around 120/80 mmHg Oxygen Saturation: Typically above 95%

6. Cont.… Abnormal Findings: Fever : Body temperature above 100.4°F (38°C) Bradycardia : Pulse rate below 60 bpm Tachycardia : Pulse rate above 100 bpm Hypoventilation/Hyperventilation : Abnormal respiratory rates Hypertension : Blood pressure above 130/80 mmHg Hypoxemia : Oxygen saturation below 90%

7. Measuring Blood Pressure Blood Pressure : The force of blood pushing against the walls of your arteries as your heart pumps it around your body. Sphygmomanometer : A device used to measure blood pressure.

8. Purpose To monitor your blood pressure to ensure it’s within a normal range. To diagnose and manage conditions like hypertension (high blood pressure) or hypotension (low blood pressure)

9. Precautions Calibrate Regularly : Ensure the device is calibrated correctly to avoid inaccurate readings. Relax Before Measurement : Sit quietly for a few minutes before taking a reading to avoid high readings caused by stress. Consistent Position : Keep your arm at heart level and support it while measuring. Avoid Certain Activities : Don’t eat, drink caffeine, or exercise immediately before measuring

10. Procedure Explain the procedure the patient Wash Your Hands Collect Necessary Equipment Ensure the patient is sitting comfortably with their back supported and legs uncrossed.

11. Cont.… The arm to be measured should be rested on a flat surface, like a table, at heart level. Wrap the sphygmomanometer cuff around the patient's upper arm, about 1 inch above the elbow . Ensure it’s snug but not too tight; you should be able to fit a finger between the cuff and the arm. Position the stethoscope's diaphragm (the flat part) over the brachial artery, which is located just inside the bend of the elbow.

12. Cont.… You can feel the pulse to find the right spot. Use the bulb to inflate the cuff. Pump it until the gauge reads about 20-30 mmHg above the point where you no longer hear the pulse through the stethoscope. Inflate the cuff rapidly, then slowly release the pressure by turning the valve on the bulb.

13. Cont.… As you slowly deflate the cuff, listen through the stethoscope for the first sound (Korotkoff sound). This is the systolic pressure , the higher number, which indicates the pressure when the heart beats. Continue to slowly release the pressure and listen until the sound disappears.

14. Cont.… The point at which the sound stops is the diastolic pressure , the lower number, indicating the pressure when the heart rests between beats. Note the systolic and diastolic pressures. For example, if the systolic pressure is 120 mmHg and the diastolic pressure is 80 mmHg, record it as 120/80 mmHg.

15. Cont.… Gently remove the cuff from the patient’s arm. Clean and store the equipment properly. Document the blood pressure reading and any relevant observations. Ensure the patient understands their results and any necessary next steps.

16. NGT Insertion (Nasogastric Tube Insertion) Nasogastric tube (NGT) insertion involves placing a flexible tube through the nose, down the esophagus, and into the stomach for various medical purposes.

17. Purpose Nutritional Support : To provide enteral nutrition to patients who cannot eat orally. Medication Administration : To deliver medications directly to the stomach. Gastric Decompression : To relieve pressure from gastric distension or obstruction. Fluid Administration : To provide hydration or electrolyte solutions.

18. Indications Patients unable to swallow due to neurological conditions, surgery, or trauma. Patients with gastrointestinal obstruction. Patients requiring enteral feeding. Patients needing gastric decompression due to conditions like ileus.

19. Contraindications Severe nasal or esophageal trauma. Recent surgery on the esophagus or stomach. Known esophageal varices. Severe coagulopathy. Uncontrolled bleeding disorders.

20. Precautions Assess for nasal and oral patency before insertion. Monitor for signs of aspiration during and after insertion. Ensure the patient's head is elevated during and after feeding/medication administration. Regularly check tube placement to prevent dislodgment.

21. Tube Placement Checking Methods 1.Auscultation Method: Inject air (10-20 mL) into the tube while listening over the stomach with a stethoscope. A "whooshing" sound indicates proper placement. 2.pH Testing : Aspirate gastric contents and test the pH. Gastric contents typically have a pH of 1-4. 3.X-ray Confirmation: The most reliable method; an X-ray can confirm the tube's position.

22. Procedure/Steps for NGT Insertion Explain the Procedure to the Patient. Introduce yourself and explain what an NGT is and why it’s needed. Discuss the steps involved, duration, and any discomfort they may feel. Obtain informed consent.

23. Cont.… Gather Supplies Nasogastric tube of appropriate size Water-based lubricant Syringe (10-20 mL) pH testing strips (if applicable) Stethoscope Tissues or gauze plaster

24. Cont.… Position the Patient Sit the patient upright at a 30-45 degree angle to facilitate insertion and reduce aspiration risk . Prepare the Tube Measure the length of tube needed by measuring from the tip of the nose to the earlobe and then to the xiphoid process. Mark this length on the tube.

25. Cont.… Lubricate the Tube Apply a water-based lubricant to the tip of the NGT Insert the Tube: Gently insert the tube into one of the nostrils, directing it posteriorly and slightly downwards. Encourage the patient to swallow or sip water if they are able, as this helps guide the tube down.

26. Cont.… Advance the Tube: Continue advancing the tube until you reach the marked length . If resistance is met, withdraw slightly and try again . Check Placement: Use one or more of the placement checking methods mentioned above (auscultation, pH testing, or X-ray).

27. Cont.… Secure the Tube: Once placement is confirmed, secure the tube with plaster or a securing device to prevent movement . Document the Procedure : Record in the patient's chart: Date and time of insertion Size of NGT used Method of placement confirmation Patient's response and any complications Instructions given to the patient regarding care and monitoring.

28. Cont.… Post-Insertion Care: Provide instructions on how to care for the tube and monitor for complications such as discomfort, aspiration, or blockage.

29. Gastric Lavage is a medical procedure that involves the irrigation of the stomach with a saline solution or water . It is typically performed to remove toxic substances, undigested food, or blood from the stomach.

30. Purpose Poisoning or Overdose: To remove ingested toxins or drugs from the stomach. Gastric Decompression: To relieve gastric distension in certain medical conditions. Preparation for Surgery: To clear the stomach before surgical procedures.

31. Indications Acute poisoning or overdose situations where the substance is still in the stomach. Gastric outlet obstruction. Severe gastrointestinal bleeding requiring visualization or intervention.

32. Contraindications Ingestion of caustic substances (e.g., alkalis, acids) due to the risk of perforation. Unconscious patients without airway protection. Recent gastrointestinal surgery. Severe coagulopathy or bleeding disorders. Esophageal varices.

33. Corrosive ingestion Acids: Hydrochloric acid (found in some cleaners) Sulfuric acid (found in batteries) Nitric acid (used in some industrial applications) Acetic acid (concentrated vinegar ) Alkalis (Bases): Sodium hydroxide (lye, used in drain cleaners) Potassium hydroxide (found in some cleaning agents) Calcium hydroxide (used in some construction materials ) Household Cleaners : Oven cleaners Toilet bowl cleaners Rust removers Some pesticides and herbicides

34. Precautions Assess the patient’s airway and level of consciousness before proceeding. Ensure that appropriate suction equipment is available in case of aspiration. Use caution in patients with a history of gastrointestinal surgery or bleeding disorders. Monitor vital signs throughout the procedure.

35. Tube Placement Checking Methods Auscultation: Inject air into the tube while listening over the stomach for a "whooshing" sound. pH Testing: Aspirate gastric contents to check for pH (typically 1-4). X-ray Confirmation : The most reliable method to confirm placement.

36. Procedure/Steps for Gastric Lavage Explain the Procedure to the Patient Introduce yourself and explain what gastric lavage is and why it is needed. Discuss the steps involved, potential discomfort, and duration of the procedure. Obtain informed consent if applicable.

37. Cont.… Gather Supplies Nasogastric tube (appropriate size) Saline solution or sterile water Syringe (60 ml or larger) Suction equipment Stethoscope ph testing strips (if applicable) Tissues or gauze Tape or securing device

38. Cont.… Position the Patient: Place the patient in a semi-upright position (30-45 degrees) to reduce aspiration risk . Prepare the Tube: Measure the length of the tube needed from the tip of the nose to the earlobe and then to the xiphoid process . Mark this length on the tube.

39. Cont.… Lubricate the Tube: Apply a water-based lubricant to the tip of the NGT . Insert the Tube: Gently insert the tube into one nostril, directing it posteriorly and slightly downwards. Encourage the patient to swallow if they are able, which helps guide the tube down.

40. Cont.… Advance the Tube: Continue advancing until you reach the marked length . If resistance is met, withdraw slightly and try again . Check Placement: Confirm placement using one or more methods (auscultation, pH testing, or X-ray ). Initiate Lavage: Attach a syringe filled with saline solution to the tube. Instill 100-200 mL of saline solution gently into the stomach. Allow time for the solution to dwell briefly (1-2 minutes).

41. Cont.… Aspirate Contents: Use a syringe to aspirate gastric contents and assess for clarity and color. Repeat the instillation and aspiration process several times until clear fluid is obtained or as directed by protocol.

42. Cont.… Document the Procedure: Record in the patient's chart: Date and time of lavage Size of NGT used Amount and type of fluid instilled and aspirated Method of placement confirmation Patient's response and any complications encountered Instructions given to the patient regarding care and monitoring.

43. Cont.…. Post-Procedure Care: Monitor vital signs and assess for any signs of complications such as aspiration or discomfort. Provide instructions on monitoring for any adverse effects post-lavage.

44. Intermittent Gavage refers to the method of delivering nutrition or medications through a nasogastric (NG) tube at scheduled intervals, rather than continuously. This approach allows for periodic feeding or medication administration while minimizing the risk of complications associated with continuous feeding.

45. Purpose To provide nutritional support to patients who cannot eat orally. To administer medications in a controlled manner. To allow for digestive rest periods between feedings.

46. Indications Patients with swallowing difficulties (e.g., stroke, neurological disorders). Patients with gastrointestinal conditions that impair normal eating. Patients requiring enteral feeding due to critical illness or recovery from surgery.

47. Contraindications Severe esophageal or gastric obstruction. Recent gastrointestinal surgery (consult physician). Uncontrolled vomiting or severe gastric distension. Known allergies to the formula being administered.

48. Precautions Assess the patient’s airway and level of consciousness before beginning. Monitor for signs of aspiration or intolerance during and after feeding. Ensure proper tube placement before each feeding session. Use caution in patients with a history of gastrointestinal issues.

49. Tube Placement Checking Methods Auscultation: Inject air into the tube while listening over the stomach for a "whoosh" sound. pH Testing: Aspirate gastric contents and check pH (should be 1-4). X-ray Confirmation: The most reliable method to confirm tube placement.

50. Procedure/Steps for Intermittent Gavage Explain the Procedure to the Patient: Introduce yourself and explain what intermittent gavage is and why it is necessary. Discuss the steps involved, potential discomfort, and duration of the procedure. Obtain informed consent if applicable.

51. Cont.… Gather Supplies: Nasogastric tube (appropriate size) Enteral feeding formula or medication Syringe (60 mL or larger) Water for flushing pH testing strips (if applicable) Tape or securing device Gloves

52. Cont.… Position the Patient: Place the patient in a semi-upright position (30-45 degrees) to reduce aspiration risk . Prepare the Tube: Measure the length of the tube needed from the tip of the nose to the earlobe and then to the xiphoid process . Mark this length on the tube if it’s not already in place.

53. Cont.… Check Tube Placement: Confirm that the NG tube is correctly placed using one or more methods (auscultation, pH testing, or X-ray ). Measure Gastric Residual Volume (GRV): Pour the aspirated contents into measuring cup and read the volume. Record the amount in milliliters (ml).

54. Cont.… Return Gastric Contents (if appropriate):   Unless contraindicated, return the aspirated contents back into the stomach through the NGT by pushing the contents from the syringe back into the tube.

55. Cont.… Prepare the Feeding Solution: If using a formula, ensure it is at room temperature and appropriately mixed. Draw up the required amount of formula into a syringe.

56. Cont.… Administer the Feeding: Connect the syringe to the NG tube. Slowly instill the formula or medication into the tube using gravity or by pushing gently on the syringe plunger. Administer at a rate that is comfortable for the patient, typically over 20-30 minutes.

57. Cont.… Flush the Tube: After administering the feeding, flush the tube with 30-50 mL of water to ensure all formula has been delivered and to keep the tube patent . Monitor the Patient: Observe for any signs of discomfort, nausea, or aspiration during and after feeding. Check for residual gastric contents before each feeding session, if indicated.

58. Cont.… Document the Procedure: Record in the patient's chart: Date and time of gavage Size of NG tube used Amount and type of formula administered Method of placement confirmation Patient's response and any complications encountered Instructions given to the patient regarding care and monitoring.

59. Cont.… Post-Procedure Care: Ensure that the patient remains in an upright position for at least 30 minutes after feeding to reduce aspiration risk. Monitor vital signs and assess for any signs of complications such as aspiration or discomfort.

60. Continuous Gavage refers to the method of delivering nutrition or medications through a nasogastric (NG) tube continuously over an extended period, typically using a feeding pump. This approach is often used for patients who require consistent nutritional support.

61. Cont.… Purpose To provide sustained nutritional support to patients unable to eat orally. To maintain caloric intake for patients with high metabolic needs. To facilitate medication administration in a controlled manner.

62. Cont.… Indications Patients with swallowing difficulties (e.g., neurological disorders, stroke). Patients with gastrointestinal conditions that impair normal eating. Critically ill patients requiring enteral feeding due to prolonged illness or recovery from surgery.

63. Cont.… Contraindications Severe esophageal or gastric obstruction. Recent gastrointestinal surgery (consult physician). Uncontrolled vomiting or severe gastric distension. Known allergies to the formula being administered.

64. Precautions Assess the patient's airway and level of consciousness before beginning. Monitor for signs of aspiration or intolerance during and after feeding. Ensure proper tube placement before each feeding session. Use caution in patients with a history of gastrointestinal issues.

65. Cont.… Tube Placement Checking Methods Auscultation: Inject air into the tube while listening over the stomach for a "whoosh" sound. pH Testing: Aspirate gastric contents and check pH (should be 1-4). X-ray Confirmation: The most reliable method to confirm tube placement.

66. Procedure/Steps for Continuous Gavage Explain the Procedure to the Patient: Introduce yourself and explain what continuous gavage is and why it is necessary. Discuss the steps involved, potential discomfort, and duration of the procedure. Obtain informed consent if applicable.

67. Cont.… Gather Supplies: Nasogastric tube (appropriate size) Enteral feeding formula Feeding pump (if applicable) Syringe (60 mL or larger) Water for flushing pH testing strips (if applicable) Tape or securing device Gloves

68. Cont.… Position the Patient: Place the patient in a semi-upright position (30-45 degrees) to reduce aspiration risk. Prepare the Tube: Measure the length of the tube needed from the tip of the nose to the earlobe and then to the xiphoid process . Mark this length on the tube if it’s not already in place.

69. Cont.… Check Tube Placement: Confirm that the NG tube is correctly placed using one or more methods (auscultation, pH testing, or X-ray ). Measure Gastric Residual Volume (GRV): Pour the aspirated contents into measuring cup and read the volume. Record the amount in milliliters (ml).

70. Cont.… Return Gastric Contents (if appropriate):   Unless contraindicated, return the aspirated contents back into the stomach through the NGT by pushing the contents from the syringe back into the tube.

71. Cont.… Prepare the Feeding Solution: If using a formula, ensure it is at room temperature and appropriately mixed. Connect the feeding bag to the feeding pump if using one.

72. Cont.… Administer the Feeding: Set the feeding pump to deliver the prescribed rate of formula continuously. If not using a pump, connect the syringe to the NG tube and allow gravity to assist in administering the formula slowly . Flush the Tube: After setting up continuous feeding, flush the tube with 30-50 mL of water to ensure all formula has been delivered and to keep the tube patent.

73. Cont.… Monitor the Patient: Continuously observe for any signs of discomfort, nausea, or aspiration during and after feeding. Check for residual gastric contents regularly as per protocol.

74. Cont.… Document the Procedure: Record in the patient's chart: Date and time of continuous gavage initiation Size of NG tube used Amount and type of formula administered Method of placement confirmation Rate of feeding set on the pump Patient's response and any complications encountered Instructions given to the patient regarding care and monitoring.

75. Cont.… Post-Procedure Care: Ensure that the patient remains in an upright position as much as possible to reduce aspiration risk. Monitor vital signs and assess for any signs of complications such as aspiration or discomfort.