nasogastric tube [NGT] insertion,feeding and removal.

Nasogastric tube insertion"NGT"

Preparation:

1. check physician's order and client care plan for insertion NGT.
2. determine size of tube.
3. prepare equipment.
4. discuss procedure with client.
5. provide privacy.
6. raise bed to appropriate working height.

Procedure:

1. wash hands.
2. face patient,stand on left side of bed if you are right handed"on right side if left handed".
3. lower side rails on working side of bed.
4. position client at 45 degree angle or higher with head elevated.
5. Don clean gloves.
6. examine nostrils,and select the most patent nostril.
7. measure from tip of nose to earlobe to xiphoid process of sternum.
8. pinch the tube.
9. lubricate first 4 inches "10 cm" of tube with water-soluble lubricant.
10. insert tube through nostril to back of throat.
11. suggest client to swallow to assist tube insertion.
12. instruct the client to flex head toward chest.
13. continue advancing tube until taped mark.
14. check position of tube.
15. aspirate the injected air. 
16. pinch the tube.
17. remove gloves.
18. tape tube securely to nose.
19. position client for comfort.
20. lower bed,and raise side rails.
21. dispose equipment.
22. wash your hands.

Giving intermittent nasogastric feeding

Preparation:

1. check physician's order and client care plan for appropriate formula "type,calories,or amount or both ,and frequency".
2. send request for prescribed formula is available.
3. check expiration date on formula.
4. warm formula to room temperature.
5. prepare feeding equipment.

Procedure:

1. check client's identification.
2. explain procedure and purpose to the patient.
3. keep patient privacy.
4. wash hands.
5. Don gloves.
6. face patient,stand on right side of patient if you are right handed"on left side if left handed".
7. raise bed to appropriate working height.
8. lower side rails on working side of bed.
9. assess abdominal distention,and auscultate bowel sound.
10. place client in high fowler's position.
11. check placement of NGT.
12. place absorbent towel at working area on bed.
13. aspirates all gastric contents.
14. measure the volume of residual.
15. check color and character of residual.
16. return aspirated residual to stomach.
17. clamp or pinch the end of the feeding tube.
18. remove plunger from barrel of syringe.
19. attach barrel of syringe to the proximal end of the feeding tube tightly.
20. flush tube before feeding with 30 ml of sterile water.
21. pinch the end of the feeding tube.
22. fill syringe with formula until grades only.
23. unclamp the feeding tube and hold syringe no more than 18 inches "45 cm" above insertion site.
24. pinch the tube before syringe runs dry and refill the syringe with formula.
25. follow tube feeding with sterile water "30 ml" or in ordered amount.
26. clamp end of the tube.
27.  keep client in high-fowler's position for 30-60 minutes after feeding.
28. with gloved hands wash,rinse and dry equipment after feeding. 
29. return equipment to client bedside.
30. provide oral and nasal hygiene.
31. remove gloves.
32. wash handes.
33. lower bed and raise side rails.

Post procedure;

document all relevant information.

Removing of nasogastric tube"NGT"

Preparation;

1. check order and client care plan for removing NGT.
2. discuss procedure with client.
3. provide privacy.
4. raise bed to appropriate working height.

Procedure;

1. wash hands.
2. face patient,stand on left side of bed if you are right-handed"on right side if left-handed".
3. lower side rails on working side of bed.
4. place client in high fowler's position.
5. place paper towel over client's chest.
6. loosen tape securing tube.
7. Don gloves.
8. clamp or plug tube.
9. take paper towel in non-dominant hand and place under chin.
10. pinch tube near nostril and remove with a continuous steady pull.
11. hold tube in paper towel.
12. dispose tube and gloves in rash.
13. Don other clean gloves.
14. clean client face especially nares.
15. offer oral hygiene.
16. remove gloves.
17. assist client to a comfortable position.
18. lower bed and raise side rails.

wash hands.

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measuring central venous pressure CVP

Preparation:

1. check physician's order and client care plan for measuring CVP.
2. Prepare equipment.
3. discuss procedure with client.
4. provide privacy.
5. lower side rails on working side of bed.
6. place client in horizontal {supine}position.
7. raise bed to appropriate working height.
8. mark an "x" with the indelible pen at the level of the right atrium.

Procedure:

1. wash hands.
2. don gloves.
3. connect the intravenous fluids to the three-way stopcock and flush the other two ports with the fluids.
4. connect the CVP manometer to the upper port of the stopcock.
5. allow IV fluid to drip rapidly into patient for several seconds,with stopcock closed to manometer.
6. turn stopcock off to patient and fill manometer with fluid.
7. hold manometer at "x" on thorax and turn stopcock off to IV fluids.
8. observe the oscillated fluid in manometer with the client's respiration.
9. take reading of CVP
   
   .
10. turn stopcock off to manometer.
11. remove manometer from stopcock,place sterile dead-end cap on upper part of stopcock and at connector site of CVP.
12. remove gloves.
13. return the patient to comfortable position.
14. lower bed,and raise side rails.
15. wash hands.
16. record in nurses' notes and or on flow sheet the CVP reading.
17. report any abnormal values to the nurse in charge or physician.

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surgical scrubbing

The purpose of surgical hand scrub is to:

Remove debris and transient microorganisms from the nails, hands, and forearms.

Reduce the resident microbial count to a minimum,and Inhibit rapid rebound growth of microorganisms.                   

The procedure consists of three phases:

hand washing.

using brush.

surgical scrubbing.                                                                                                                  The procedure for the timed five minute scrub consists of:                                          

1. Remove all jewelry (rings, watches, bracelets).
2. cover any cut on the skin.
3. adjust the water.
4. wet your hand.
5. Wash hands and arms with antimicrobial soap fig{1}. 
6. use brush for cleaning your nails 30 times in one direction.
7. remove the brush.
8. wash your nails.
9. with or without using a sponge  Scrub each side of each finger for 10 times , between the fingers, and the back and front of the hand for two minutes.{four sides for each finger }.
10. Proceed to scrub the forarms, keeping the hand higher than the arm at all times.{This prevents bacteria-laden soap and water from contaminating the hand}.
11. Wash each side of the arm to three inches above the elbow for 10 times.
12. Rinse hands and arms by passing them through the water in one direction only, from fingertips to elbow. Do not move the arm back and forth through the water.
13. Proceed to the operating room suite holding hands above elbows.

Once in the operating room suite, hands and arms should be dried using a sterile towel and aseptic technique. You are now ready to don your gown and sterile gloves.

hand washing fig{1}.

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Intravenous Cannulation (IV)

 steps of IV cannula insertion

1. Introduce yourself to the patient.
2.  clarify the patient’s identity.
3.  Explain the procedure to the patient and gain informed consent to continue. It is also worth explaining that cannulation may cause some discomfort but that it will be short lived. 
4. maintain patient privacy.
5. gathering equipment.

• alcohol.
• Iv cannula {ensure size matches with patient age}.
• disposable tourniquet.
• gloves. 
• sharp bin.
  
  
  
• syringe.
• saline.
• suitable plaster.

1. wash hands.
2. Position the arm so that it is comfortable for the patient and identify a vein.
3. Put on your gloves, clean the patient’s skin with the alcohol wipe and let it dry.
4. Remove the cannula from its packaging and remove the needle cover ensuring not to touch the needle.
5. Stretch the skin distally and tell the patient to expect a sharp scratch.
6.  Insert the needle, bevel upwards at about 30 degrees. Advance the needle until a flashback of blood is seen in the hub at the back of the cannula.
7. Once this is seen, progress the entire cannula a further 2mm, then fix the needle, advancing the rest of the cannula into the vein.
8. Release the tourniquet, apply pressure to the vein at the tip of the cannula and remove the needle fully. Remove the cap from the needle and put this on the end of the cannula.
9. Carefully dispose of the needle into the sharps box.
10. Apply the dressing to the cannula to fix it in place and ensure that the date sticker has been completed and applied.
11. Check that the use-by date on the saline has not passed. If the date is ok, fill the syringe with saline and flush it through the cannula to check for patency. If there is any resistance, if it causes any pain, or you notice any localised tissue swelling; immediately stop flushing, remove the cannula and start again.
12. Dispose of your gloves and equipment in the clinical waste bin, ensure the patient is comfortable.

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