Abdominal assessment
order of assessment techniques for abdomen
auscultate
percuss
palpate
Enteral tubes can be placed into what two organs?
stomach and intestine
name the 3 tubes used for decompression
Levin (OG or NG)
Cantor (NG)
Salem Sump (OG or NG)
What degree does the HOB need to be at during and 1 hr after feedings?
30-45 degrees
what is the first and most accurate way to confirm placement BEFORE you can begin to use an enteral tube at all
X-ray
how should you position your pt for an abdominal assessment
lying flat; have pt empty bladder prior
how many lumen does a salem sump tube have?
2
what is the benefit of intermittent suction?
prevents stomach wall irritation/ulcer
prevents tube from sticking to wall of stomach
when do you need to check residuals during continuous feedings
Q4 hrs
how to verify placement after X-ray has been obtained
verify pH
measure external length
list abnormal findings upon inspection
- striae
- umbilical hernia
- distention
- ascites
true or false: Gastrostomy and Jejunostomy tubes go through the nose
False - these are surgically placed and exit the abdominal wall
what should the pH of stomach contents be? what color do you want to see?
5.5 or less
grassy green
what controls the rate of administration with a gravity feeding set-up?
height of syringe/bag
nursing interventions to manage an enteral tube
frequent oral care
assess insertion site for irritation/skin breakdown
keeping tube from being pulled (ie pin to gown)
abdominal assessment
flushing/irrigation according to policy
how long should you listen to confirm absent bowel sounds?
2 mins/quadrant
what does NG stand for?
nasogastric
if you needed to give a med while enteral tube is being used for decompression, how long should you keep the tube clamped for after rx admin?
30 mins
s/s of dumping syndrome
gas, bloating, ND, cramping, and lightheadedness
do you need to count flushes for I/O documentation?
YES
why should you never palpate a pulsating midline mass?
it is most likely a AAA
(abdominal aortic aneurysm)
what would be an indication for an enteral tube?
- poison consumption
- absent bowel sounds + distention
- need for bowel rest (ie bowel obstruction)
- dysphagia
what are potential complications from decompression?
migration/dislodgement
clogged tubing
skin breakdown
stomach mucosa damage
what are potential complications of feeding via enteral tube?
aspiration, migration/dislodgement, intolerance, clogged tubing, skin breakdown, infection, dumping syndrome
What important instruction should you give your pt when removing an NG tube?
hold their breath! (prevents accidental aspiration)