Lab 6 & 8 - GI Modalities & Injections

What are the 3 purposes of a nasogastric tube?

Lavage (rinsing the stomach, e.g. charcoal for overdose), decompression (suction for distended abdomen, e.g. SBO), gavage (feeding)

Is NG tube insertion sterile or clean?

Clean; the GI tract isn't sterile

How do you measure an NG tube?

Tip of nose to ear to xiphoid process

How is the pt positioned for NG insertion?

Seated with the head tilted slightly forward

What helps the tube pass into the GI tract?

Pt swallows, with sips of water unless the pt is aspirating

What should you do if the pt coughs during insertion?

Stop (don't pull it out), have pt breathe, then continue

What lubricant is used for tubes?

Water-soluble only, never petroleum-based

What should you document after inserting an NG tube?

The centimeter marking at the naris; keep checking it for migration

What is the purpose of the stylet?

Keeps the tube stiff during insertion; removed after placement

What is the gold standard for confirming NG placement?

Chest x-ray, before the tube is used, to prove it isn't in the lungs

What are complications of an NG tube?

Aspiration (biggest risk), discomfort, skin breakdown at the naris

Head of bed must be at least __________ during tube feeding

30 degrees

What must you do before laying a tube-fed pt flat?

Shut off the feeding, then restart after sitting pt back up

What do you monitor during tube feeding?

N/V, fluid and electrolyte imbalance, aspiration, diarrhea (common when starting)

When is a gastrostomy tube used?

Long-term feeding; placed through the skin into the stomach

When is a jejunostomy tube used?

When the pt has no stomach (e.g. gastrectomy); placed surgically into the jejunum

Which feeding suits a pt with heart failure and why?

Concentrated formula (more calories per mL), so less volume is given

Why do tube-fed pts need extra water orders?

Feedings may not have enough water, e.g. 250 mL every 6 hrs

How should a feeding bag be labeled?

Pt name, product, rate, volume, date and time, like a medication

Which form of medication is best through a feeding tube?

Liquid; ask pharmacy and the HCP

Which medications can't be crushed?

Long-acting and enteric-coated tablets

What is done before and after giving meds through a feeding tube?

Flush with plain water to prevent clogging

What are the two types of enemas?

Small volume: medicated or laxative (Fleet, steroids for IBD); Large volume: tap water or soap suds (castile soap), usually 1-1.5 L

What water is used for a tap water enema?

Regular tap water at room temperature or slightly warm; not sterile water

Why not use cold or hot water for an enema?

Causes cramping and discomfort

What position is used for an enema?

Sims: left side with right knee bent toward the chest

How far is a large-volume enema tube inserted?

4-5 inches

What should you do if a pt cramps during an enema?

Clamp the tubing (leave it in), deep breaths, restart when it eases

How long should a pt hold an enema?

As long as possible so stool absorbs fluid and softens, or medication absorbs

What are complications of enemas?

Abdominal cramping and bowel perforation; use lots of lubricant and never force the tube

What does occult mean and what is another name for the test?

Hidden blood; guaiac test

What is the first step with the card?

Check the control: developer on the circles should turn the pale circle darker

How is stool added to the card?

Small smear in box A from one part of stool and box B from a different part; liquid or solid both work

How many drops of developer are used?

1-2 drops

What color is a positive occult blood test?

Dark blue

(T/F) A stool card can be used to test emesis

False; the wrong card or developer can give false results

What is an ostomy?

Surgically created passage that drains urine or stool; temporary (rest or heal the bowel) or permanent (cancer, large resection)

What is a stoma?

End of the bowel or ureter that is visible on the abdomen

What does a healthy stoma look like?

Smooth, red (beefy red), shiny, moist; highly vascular

What is expected right after ostomy surgery (lab slides)?

Swelling for first 5-10 days; small bleeding at the suture line for 1-2 days

(T/F) A pt will report pain if the stoma becomes necrotic

False; no nerve endings, so careful assessment is vital

What is an ileostomy?

Small intestine to abdominal surface, often lower right; liquid output with more digestive enzymes; odor less noticed

What is the critical nursing consideration for an ileostomy?

Protect the skin from liquid output and digestive enzymes

What is a colostomy and its output?

Any section of the large intestine; the closer to the rectum, the more formed the stool bc the colon absorbs water

What is a double-barrel colostomy?

Two stomas: proximal makes stool; distal (connected to the rectum) makes mucus

What is a ureterostomy?

Ureter diverted to the abdominal surface; highest infection risk

What are the nursing diagnoses for ostomy pts?

Impaired skin integrity, disturbed body image, deficient knowledge, ineffective coping, risk for infection

How should a nurse behave during ostomy care?

Professionally, without reacting to odor or secretions; every pouch change is a teaching opportunity

Compare one-piece vs two-piece pouches

One-piece: pouch and skin barrier together, change the whole thing; Two-piece: faceplate cut to size plus a bag that snaps on, bag can change alone

How should the skin barrier fit?

Snug, not tight: too big leaks; too small strangles the stoma

How do you size the appliance?

Measuring guide, then cut the opening; cut to shape for irregular stomas; warm the barrier with fingers to mold it

How often is an appliance changed (lab slides)?

Colostomy and ileostomy every 5-7 days (textbook 4-7); ureterostomy every 2-3 days; check agency policy

When must an appliance be changed right away?

Leaking, a loose seal, or pt discomfort

When should a pouch be emptied?

1/3 to 1/2 full; a heavy pouch leaks or pulls loose; release gas as needed

What causes skin excoriation around a stoma?

Stool and digestive enzymes on the skin: pain, itching, burning

What causes mechanical irritation and how do you prevent it?

Removal technique or friable skin (older adults, long-term steroids); remove slowly, pushing the skin away from the appliance

What are signs of ostomy infection?

Redness, swelling, tenderness, discharge, fever, high WBC; Staph on the skin or from the surgical wound

What causes stoma prolapse?

Weak abdominal muscles or increased abdominal pressure (coughing, straining); can be 1-2 feet of bowel; usually painless but terrifying

What is the care for stoma prolapse?

Notify provider urgently, keep moist with saline gauze, assess color; manual correction by clinician, surgery often required

How do you read a syringe?

At the top black line of the plunger

Which parts of the syringe and needle must stay untouched?

Plunger shaft, tip and needle hub

What does a higher gauge number mean?

Smaller needle diameter

What do you base needle and syringe choice on?

What you're giving (oil or water based), site and technique (ID, SC, IM), body habitus

What is a TB syringe?

1 mL, the only syringe marked in hundredths

What is an insulin syringe?

1 mL holds 100 units

Which way does the bevel face when under 90 degrees?

Up, so the sharpest part enters first

What are the rules for recapping?

Never recap after an injection; before an injection, recap one-handed

What goes in the sharps container?

All syringes, with or without a needle

How do you open an ampule?

Move all medication below the neck, wrap in gauze, snap away from you; top goes in sharps

Why is a filter needle used with ampules?

Filters tiny glass pieces; it is never used to inject

What is a blunt fill needle?

Draws from a vial; no point, so never used to inject

How do you prepare a vial?

Scrub the rubber top with alcohol for 30 seconds and air dry, inject air equal to the dose, invert, keep needle tip below fluid, draw up

Why remove air bubbles?

Air takes up space where medication should be: underdosing

Why change the needle before injecting?

Going in and out of vials dulls it

What do you do with a single-dose vial after use?

Discard, even if medication remains

What do you write on an opened multidose vial?

Date, time and initials

How long is an opened multidose vial (e.g. insulin) good for?

28 days, regardless of the printed expiration date

What is the order for mixing a vial and an ampule?

Draw from the vial first, then use same syringe and a filter needle for the ampule

What are the rules for mixing two vials?

Don't contaminate one with the other; keep the final dose accurate; aseptic technique

What is reconstitution?

Turning a powdered medication into a parenteral liquid using a diluent

How do you choose how much diluent to add?

Use the vial's chart and pick the concentration based on the order

Order is 800 mg and the chart gives 400 mg/mL. How much do you give?

2 mL

How do you mix a reconstituted drug?

Roll it, never shake; check that all powder is dissolved

How long is a reconstituted drug or medication in an IV bag good for?

24 hours

How do you add medication to an IV bag?

Inspect bag, scrub med port for 30 seconds, inject, mix, label

Where does the IV bag label go?

On the back, so the barcode stays visible

What goes on an IV medication label?

Pt name and room, drug and amount, added by, base solution, date and time, start time, flow rate, expiration

What are the guidelines for intradermal injections?

Under 1 mL; 26-32 g; 1/2-5/8 in; 5-15 degrees; inner forearm or scapula

What are the guidelines for subcutaneous injections?

0.5-1.5 mL; 23-32 g; 3/8-5/8 in (3/16 in for insulin); 45-90 degrees

What are the guidelines for IM injections?

2-5 mL by site; 19-25 g; 1/2-2 in; always 90 degrees

What are the subcutaneous sites?

Outer posterior arm, abdomen 2 in from umbilicus, anterior thighs, upper back at scapula, upper buttocks

What angle is insulin given at?

90 degrees ONLY

How are insulin sites rotated?

Within the same body part, 1 in from the last site; 1 month before reusing a site

What are the IM volume limits by site?

Deltoid under 2 mL; vastus lateralis and rectus femoris 2 mL or more; ventrogluteal over 2 mL; dorsogluteal 3 mL or more

(T/F) IM volumes over 3 mL are recommended

False; over 3 mL isn't well absorbed

What is the best IM site for adults?

Ventrogluteal

What is the best IM site for children?

Thigh sites (0.5-2 mL); ventrogluteal only if volume is 2 mL

Why avoid the dorsogluteal site?

Risk of hitting the sciatic nerve

What is the IM limit for a child, older adult or thin pt?

0.5-2 mL at any site

When do you aspirate?

All IM injections except vaccinations (per CDC)