Fun - Psy.dtu by Dejen G.

Debr-Tabor University,
College of Health Sciences
Department of PSYCHIATRIC Nursing
8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

Foundations of Psychiatric nursing
CHAPTER:-ONE :-Naso Gastric Tube

Objectives: On the completion of the lesson
students will be :-
Define Nasogastric tube.
List the purpose of nasogastric tube.
Collect the necessary equipment for nasogastric tube
insertion .
Perform the procedure according to the steps.
Apply proper checking of NG tube placement.

.

Naso- Gastric Tube con..
Definition:- Passing a tube through a nasal cavity down the nasopharynx

and oesophagus in to the stomach
Purpose
To administer tube feeding and medication to clients unable to eat by
mouth or swallow a sufficient diet without aspirating food or fluids in to
the lungs.
To establish a means for suctioning stomach contents to prevent gastric
distension, before and after surgery ,nausea and vomiting
To remove stomach contents for laboratory analysis
To relieve vomiting and distention
To lavage (wash) the stomach in case of poisoning or overdose of
medications

Purpose Con
To prevent stress on operated site by decompressing

stomach of secretions and gas
To instill ice cold solution to control gastric bleeding

Indication
Surgery
Abdominal distension
Poison
Unconscious
Severe dehydration
Diagnostic analysis

Type of Gastric tubes
The two most commonly used nasogastric tubes are:

1. The single - lumen Levin tube and
2. The double lumen gastric sump tube/salem tube
Gastric tubes are used in adults primarily to remove fluid and
gas from the GI tract this is called decompression.
They are occasionally used the short term (3 to 4 weeks)
administration of medication or feeding.

1. Levin tubes
Has a single lumen.
-
Made of plastic or rubber openings near its tip.

The tube is connected to low intermittent suction (30to40mmHg) the
suction is used to avoid erosion or tearing of the stomach lining.
Used for short term tube feeding because such tubes are relatively rigid
and have large diameter compared with nasal passage discomfort and
mucosal breakdown are common with prolonged therapy. The Levin
tube is a single lumen tube sized according to the French (Fr) method
sizes 14 to 18 Fr are typical adult sizes, with a length of 120cm (48in).
Small openings at the tip end of the tube allow for fluid flow in or out of
the tube
A marking at specific points on the tube serves as measurement
guidelines for length of tube to be inserted.

2. Gastric sump
The gastric sump (Salem) tube is a clear plastic double lumen NG tube
used to decompress the stomach and keep it empty.
It is 120cm long.
The gastric sump tube is a clear plastic, double lumen tube also sized
according to the French method. Gastric sump tubes are preferred tubes
for decompression
The larger lumen is connected to suction and drainage container to
collect the aspirated gastric content and the smaller second lumen
terminates in a blue vent which is always open to the air, providing
continuous atmospheric air irrigation

3. Enteric tubes
Naso- enteric tubes are used for feeding.

Feeding tubes placed in the duodenum are 160cm long and called
naso -duodenal tubes.
Feeding tubes placed in the jejunum are 175cm.

Contraindications
A. Absolute Contraindications
are:
Non-functioning GI tract e.g. ileus.
Obstructive pathology in oropharynx or esophagus preventing passage
of the tube e.g. stricture, tumour, pharyngeal pouch.
Large gastric aspirate and/or high risk of aspiration.
Intractable vomiting not resolved by anti-emetics
Basal skull fracture, as the tube may enter the brain if incorrectly
positioned (oro- gastric positioning may be appropriate).

Contraindication CON..
B. Relative Contraindications:
NG Tube placement is not an absolute no for these patients but it will
be dependent on how each patient with these symptoms presents and
the medical team will make the final decision on whether NG tube
placement is possible.
Oesophageal varices
Mucositis
Vomiting responding to anti-emetics
Recent radiotherapy to head and neck
Advanced neurological impairment

Advantages and Disadvantages of NG Tubes
Advantages
Readily available
Easily inserted
Easily reversed
Rapid start of enteral feeds
Few contraindications to placement
Disadvantages
Easily dislodged
Uncomfortable
Aesthetically displeasing

complications
Common complications
Pulmonary intubation
Pulmonary aspiration
Reflux
Nasal and mucosal ulceration
Rarer complications
Epistaxis
Gastrointestinal bleeding
Esophageal gastric and duodenal perforation
Pneumothorax

Checking Tube Position
1. pH testing
2. x-ray.
3. Auscultation of air insufflated through the tube (whoosh test)
4. Testing aspirate with Blue Litmus paper
5. Interpreting absence of respiratory distress as
6. Monitoring bubbling at the end of the tube
7. Observing the appearance of the aspirate

Equipment
NGT, (Ryles tube) plaster,
Gauze
Disposable glove
Glass of water
20 to 50 ml syringe
Stethoscope
Blue litmus paper
Ink
Spigot to close the tube
Cotton applicator to clean nostril
Waster receiver
Rubber sheet and draw sheet
Mouth wash tray
Tongue depressor
Flash light
Basin with warm water or ice
Denature cup
Safety pin and rubber band
Bath towel
Normal saline
Emesis basin( bowel)
8/8/2017 Clamper or artery forcepsFUNDAMENTAL

to clamp theOFtube to avoid
NURSING air entry
BY DEJEN G.
Procedure
1. Explain the procedure to the patient
2.Wash hands and prepare equipment's
3.Position:
.For conscious patient sitting or a semi-upright position and
support the head on a pillow It is often easier to swallow in this
position and gravity helps the passage of the tube
For unconscious patient lying in the left lateral position with the
head slightly lower than the body.
For infants and young children, do not hyper extend or hyper flex the
neck may occlude air way but in young person ask to hyper extend
the neck
4. Done examination glove
5. Drape plastic sheet and lower around patients neck.
6. Assess clients necks

Procedure CON
7. After hyperextend the head of the client observe the patent of the
tissues of the nostrils, including any irritations or abrasions by using a flash
light and examine the nares for any obstructions or deformities by asking
the client to breathe through one nostril while occluding the other
a. Check that the nostrils are patent by asking the patient to sniff with one
nostril closed
b. Repeat with the other nostril. If necessary cleanse the nostrils with water
using cotton wool on applicator.
8. Prepare the tube for insertion. If a rubber tube is being used, place it on
ice this stiffens the tub, facilitating insertion. If a plastic tube is being used,
place it in warm water. This makes the tube more flexible, facilitating
insertion
9. Use the tube to mark off the distance from the tip of the clients nose to
the tip of the ear lobe and then from the tip of the earlobe to the tip of the
sternum. This distance varies among individuals. For infant and young
children, measure then to the point midway between the umbilicus and the
xiphoid process. Mark this length with adhesive tape /ink if the tube does
not have markings.
Procedure CON.
10. Lubricate about 15-20 cm of the tube with a water soluble lubricant
using a swab
11. Insert the rounded end of the tube in hyper extend the neck in to the
cleanest nostril and slide it backwards and in wards along the floor of the
nose to the nasopharynx.
a. If any obstruction is felt, withdraw the tube and try again in a slightly
different direction or use the other nostril.
12. As the tube passes down in the nasopharynx, ask the patient to start
swallowing and sipping water this will close the glottis, enabling the tube to
pass in to the oesophagus.
a. Slight pressure is sometimes necessary to pass tube but never forced
against resistance, because of the danger of injury

Procedure CON.
13. Advance the tube through the pharynx, as the patient swallows until
the predetermined mark has been reached.
While inserting the tube observe for patient condition for Coils in the
mouth by opening the mouth by tongue depressor
If Client gag, stop passing the tube momentarily with each wall insert 5
to 10 cm with each swallow.
If client continues to gag and the tube does not advance with each
swallow, withdraw it slightly.
If the patient shows signs of distress like gasping or cyanosis, remove the
tube immediately and try again the procedures.
14. Continue in advancing the tube until the mark on and the tube reach
his/her nostril.
15. Taping a tube to the bridge of the nose

Procedure CON.
16. Check the position of the tube to confirm that it is in the stomach by:-
A. Introducing 10-20ml of air in to the stomach via the tube and check for a
whooshing sound using a stethoscope placed over the epigastrium.
B. Aspirating the contents of the stomach with a syringe. The aspirate turns
blue litmus paper to red, due to HCI.
C. Insert/immerse the tip of tube in the glass of water and if you see bubble
that show you are in the lung.
17. Clamp the end of the tube with clamper or forceps or spigot
18. Secure the tube to the nostril and attach to forehead with adhesive
tape. Ensure patient is comfortable.
19. Attach the tube to a suction source or feeding apparatus as ordered
20. Assist the patient into position and comfort
21. Remove and clean the used equipment return it in to proper place
22. Wash hands and dry
23. Document relevant information

Nursing Management
Preparing the patient _ explaining to the patient the purpose of the

tube and the procedure required for inserting.
Inserting the NG tube _ before inserting the tube the nurse measure the
length of tube. The length is determined by
1. Measuring the distance from the tip of the nose to the ear lobe
2. Then from earlobe to the xyphoid process adding 6 inch for NG
placement or 8to 10 inch for intestinal placement

Nursing Management CON
The patient is placed in fowlers position and the nostrils are inspected
for any obstruction.
The more patent nostril is selected for use.
The tube is aligned to enter the nostril when the tube reaches the
nasopharynx the patient is instructed to lower the head slightly and to
begin to swallow as the tube is advanced. The patient may also sip water
to facilitate advancement of the tube.
The oropharynx is inspected to ensure that the tube has not coiled in
the pharynx or mouth.
Confirming tube placement _ to ensure patient safety it is essential to
confirm that the tube has been placed correctly.

Nursing Management CON.
A combination of three methods is recommended to check the tube has

been inserted.
Measurement of the tube length
Visual assessment of aspirate
PH measurement of aspirate
After the tube is inserted the exposed portion of the tube is measured
and the length is documented.
Visual assessment of the color of the aspirate may help identify tube
placement. Gastric aspirate is most frequently cloudy and green, off
white or blood or brown.
Intestinal aspirate is primarily clear and yellow.
Pleural fluid is usually pale yellow and serous and tracheobroncial
secretion are usually off white mucus

Nursing Management CON..
Visual inspection is less helpful when the patient is receiving continuous

tube feeding because the gastric or intestinal aspirate often looks like
the formula being used for the feeding.
Determining the PH of tube aspirate is a more accurate method of
confirming tube placement.
The PH method can also be used to monitor the advancement of the
tube into the small intestine.
The PH of gastric aspirate is acidic (1to5) the intestinal aspirate is
approximately 6 or higher and the respiratory aspirate is more alkaline (7
or greater).
The PH method is less helpful with continuous feedings because tube
feedings have a PH value of 6.6 and neutralize the GI PH.

Securing the tube_ after the correct position of the tip of the tube has
been confirmed the NG tube is secured to the nose.
If NG tube is used for decompression it is attached to suction.
It is important to keep an accurate record of all fluid intake feeding and
irrigation.
To maintain patency the tube is irrigated every 4to6hours with water or
normal saline to avoid electrolyte loss through gastric drainage.
The nurse records the amount, color and type of all drainage every 8
hours.
Regular oral and nasal care is a vital part of patient care. Moistened
cotton tipped swabs can be used to clean the nose. The nasal tape is
changed every 2to3 days and nose is inspected for skin irritation.
If the nasal and pharyngeal mucosa are excessively dry steam or cool
vapor inhalation may be beneficial.

Monitoring and managing potential complication patient with NG tube

or nasoenteric intubations are susceptible to a variety of problems
including fluid volume deficit, pulmonary complication and tube related
irritation.
Symptoms of fluid volume deficit include dry skin and mucus membrane,
decreased urinary output, lethargy and increased heart rate.
Pulmonary complication from NG tube occurs because coughing and
clearing of the pharynx are impaired.
S/s of complication includes coughing during the administration of foods
or medication difficulty clearing the airway, tachypnea and fever.
Irritation of mucous membranes is a common complication of NG
intubations

Removing the tube
Removing the tube_ before the tube is removed it is flushed with 10ml
of water or normal saline to ensure that is free of debris and away from
the gastric lining.
The tube is withdrawn gently and slowly until the tip reaches to the
esophagus (15to20) the remainder is withdrawn rapidly from the nostril
force should not be used. As the tube withdrawn it is concealed in towel
to prevent secretion from soiling the patient or nurse. Then the nurse
provides oral care.
A nasointestinal tube is withdrawn at intervals of 10 minutes until the
end reaches the esophagus. If the tube does not come out easily, force
should not be used, and the problem should be reported to the
physician. As the tube is withdrawn, it is concealed in a towel, because
the sight of it may be unpleasant to the patient.
After the tube is removed, the nurse provides oral hygiene

Removing the tube

Gastric lavage
Objective:-On the completion of the lesson learners will be:

Define gastric lavage.
List the purpose of gastric lavage.
Collect the necessary equipment for gastric lavage.
Perform the gastric lavage according to the steps.

Gastric lavage
Definition:- Gastric lavage is the introduction of solution into the
stomach and removing gastric contents through nasogastric tube for
washing out the stomach.
Gastric lavage, also commonly called stomach pumping or gastric irrigation,
is the process of irrigation or washing or cleaning out the contents of the
stomach.

Purpose
To remove inserted poison, other than corrosive substances like

ammonia and mineral substances.
To introduce ice water or normal saline solution in tackling bleeding.
To cleanse the stomach before operation.
For diagnostic purposes.
To relief congestion, nausea and vomiting .

Indication
Pyloric stenosis
Poisoning
Preoperative care

Contraindication
when patients have a compromised, unprotected airway

patients at risk of gastrointestinal hemorrhage or perforation.
poisoning is due to a corrosive substance, hydrocarbons or for poisons
that have an effective antidote
Gastric emptying is also not indicated if the patient had prior repeated
vomiting or the toxin is absorbed rapidly, or patient presents late after
ingestion.
However, some toxins (antidepressants, phenothiazines, salicylates,
opioids, phenobarbital and anticholinergics) delay gastric emptying

Complications
The most dangerous risk is aspiration pneumonia, which is

more likely to occur if hydrocarbons are ingested or in
patients without a protected airway.
Other complications include laryngospasm, hypoxia,
bradycardia, epistaxis, hyponatremia, hypochloremia, water
intoxication, or mechanical injury to the stomach

Equipment's
Equipment's for NG tube insertion
Measuring jug
2-3 litters prescribed solution.
IV stand
Tap water or ice if ordered
50ml syringe
Funnel
Gloves
Rubber and cotton sheet
Towel
Litmus paper
Suction machine (optional)
Labeled specimen container
Laboratory request form
Charcoal tablets ( universal antidote)
Emesis basin
Tissue paper
Drainage container
Vital sign instruments
Chart

Procedure
2. Wash your hand
3. Assemble the necessary equipment's.
4. Keep patient privacy and position the patient
Position in left lateral position for conscious patient but if unconscious, place
in prone position with head over the edge of the bed or head lower than the
body (semi prone position)
( Elevate head of the bed at least a 45 angle or higher, if pt is conscious
Place comatose clients in semi-Fowlers position.)
5. Protect client and bed linen with towel and rubber sheet
6. Done single use examination glove
7. Select the appropriate distances mark on the tube by measuring the distance
on the tube from the clients bridge of the nose to ear lobe plus the distance
form ear lobe the to the bottom of the xiphistemu(xyphoid process).
Measure the tube from the tip of the nose up to the ear lobe and from the
bridge of the nose to the end of the sternum. (32 36 c.m.)

Procedure con..

Procedure con..
8. Lubricate the tube.
9. Gently insert and pass the tube, the tongue, the mouth forward the
posterior pharynx (If the client is unconscious, mouth gag may be used)
-If air bubbles, cough and cyanosis are noticed withdraw the tube and
recommence the procedure.
10. Advance the tube slowly to prevent injury until the pre measured mark,
11. After inserting check the placement,
A.place funnel end in a basin of water to check if the tube is in the air
passage.
-if it is in the trachea there will be bubbling so remove quickly
A.Place stethoscope on the epigastric area and auscultate hushing sound,
pushing 5-10 ml of air in to the NG tube at the same time
-If in the gastric area you will auscultate the sound
c. Aspirate some amount of fluid from the tube and check with blue litmus
papers,
If it is in the gastric the blue lithmus paper will change to red.
Procedure con..
13. Once you confirm proper placement of the tube, begin gastric lavage by
instilling about 250ml of irrigating solution to assess the patients
tolerance and prevent vomiting
If you are using simple rubber tube for the lavage
a. Fill the small jug with water/ solution, measure and pour gently until the
funnel is empty, then invent over the pail (the funnel is connected with the
funnel end of the esophageal tube)
b. Take specimen, if required, and continue the process until the returned
fluid becomes clear and the prescribed solution had been used.

Procedure con..
If you are using a tube with a bulb

a) Clamp the tube below the bulb,
b) With right hand, squeeze the bulb thus forcing the air out through the
funnel.
c) With left hand, pinch tubing above the bulb/proximal to you/ and at the
same time with right hand, release the clamp. This creates a suction which
will draw the stomach contents into the bulb.
d) Lower funnel and allow excess gastric contents to drain into the pail.
e) Pour 200-300 cc of solution/water into funnel. Before funnel is empty
allow solution to drain.
f) Before a solution stops running. Turn up funnel and add another quantity
of solution
g) Repeat this procedure until returns are clean

Procedure con..
14. Instruct the client to take deep breath and hold it to close epiglottis
15. Monitor patients vital signs, urine output, and level of consciousness
every 15 minutes and notify the physician for any changes.
16. Give mouth wash
17. If ordered, gently remove the tube, feel the clients tube, and watch the
respiration
18. Remove glove, hand wash, Clean or discard used equipments.
19. Comfort the patient
20. Record the procedure, including the time, date, type of irrigating
solution and the amount of gastric contents drained.

Gastric aspiration
Objective at the end of this lesson, the learner will able to:-
1. Define gastric aspiration
2. List the purpose of gastric aspiration
3. Collect the necessary equipment for gastric aspiration
4. Perform the gastric aspiration according to the steps

Gastric aspiration CON
Definition: Aspiration is the withdrawal of fluid or gas from

gastric cavity by sectioning.
Gastric content analysis is examination of the contents of
the stomach, primarily to determine the quantity of acid
present and incidentally to ascertain the presence of blood,
bile, bacteria, and abnormal cells.

Purpose
1. To relieve stomach or intestinal distension following

abdominal surgery.
2. In case of gastrointestinal obstruction to remove the
stomach content,
3. To keep the stomach empty before an emergency abdominal
operation is done.
4. To aspirate the stomach contents for diagnostic purpose ,like
detect acid-fast bacillus in a client with undiagnosed
tuberculosis, total absence of hydrochloric acid is diagnostic of
pernicious anemia.

Types of gastric aspiration
There are two types of gastric aspiration

1.Intermittent method:
Aspiration is done as condition requires and as ordered
2.Continuous method:
Aspiration is done continuously attached to a drainage bag.
The continuous method is indicated when it is absolutely
necessary and desirable to keep the stomach and duodenum
empty and at rest.

Ways of supplying suction
There are 2 ways of supplying suction

A. Simple suction by the use of a syringe
B. An electric suction machine

Suction apparatus

CON
Administer IV fluid to prevent dehydration, fluid and

electrolyte imbalance
Only low pressure suction used to apply because negative
pressure may cause much damage

N.B
Special care of the nose and the mouth to prevent dryness

should be considered
Always measure the amount withdrawn accurately noting
color, contents, and smell.
Record on the fluid chart properly
Irrigate frequently NG tube by normal saline to maintain its
patency.
Report any change in patient condition regarding pulse,
temperature, BP, fluid output

Equipment's
Nasogastric tube (NGT)
Syringe with needle((2)
50ml syringe
Towel
Water with kidney dish
Specimen container
Sphygmomanometer
Litmus paper
Adhesive tape
Chart
Tray
Gauze
Draw sheet rubber sheet
Spigot
Stethoscope
Water base lubricant
Scissor
Ink
Histamine
Cotton applicator
Spatula
Procedure

2. Wash hand
3. Assemble the necessary equipment's
4. Put on gloves and use the cotton and rubber sheet to cover
the bed.
5. Put up the client to high- fowler's (semi sitting) position by
raising the bed or with the help or back rest pillow.
6. Place towel on the patients chest.
7. Examine the patency of nostrils by hyper extending the head.
Ask the client to breathe through each nostril while
compressing the other nostril to select the more patient one.
Select the nostril through which air passes more easily.

Procedure CON
8. Determine length of tubing to be inserted by measuring NGT from tip of
ear lobe to tip of nose then to tip of xyphoid process and then. Mark tubing
with adhesive tape or note striped making already on the tube.
9. Clean the nostril and lubricate 20-30 meter of the tip of the tube with
water soluble lubricant to reduce friction
10. Gently insert the tube, with its natural curve toward the client, into the
selected nostril. Have the client hyper extend the neck, and gently advance
the tube toward the nasopharynx. And direct the tube along the floor of the
nostril in dawn ward and back ward way. If the tube meets resistance
withdraw it, lubricate it, and insert in the other nostril. Swallowing or
sipping water through a straw may be helpful.
11. Once the tube reaches the throat / oropharynx/, have the client tilt the
head forward and tell him to swallow.

Procedure CON
12. Instruct the client to open his/her mouth to make sure that the tube is
not coiled in the mouth and it is in the stomach.
13. Insert the tube until it reaches about 50 centimetres or until it reaches
the measured point.
14. Determine that the tube is in clients stomach.
Place the tip of the tube in the water in kidney dish; if bubbling happens
it indicates that the tube is in respiratory system, immediately remove
the tube.
Or aspirate 20-30ml of the content of the stomach with syringe then test
the content by using Litmus paper. Gastric content is yellow to green in
colour and usually presents in amounts greater than 10 ml.
Take 10 cc syringe aspirate air and administer the air through NG tube,
place stethoscope on epigastric area then listen to a gurgling sound. If
you hear the sound it means that the tube is wit in the stomach.
Chest x- ray

Procedure CON
15. After being sure that the tube is in the right position secure the
tube by taping to bridge of the client's nose
16. Aspirate gastric fluid using 20-50 ml syringe and collect specimen
if needed, or aspirate with suction machine or attach with bag or
clamp end of tubing as ordered.
17. Histamine will be given subcutaneously to stimulate gastric
secretions.
18. Continuously monitor the blood pressure to detect hypotension.
19. Collect gastric specimen every 15 minutes for 1 hour.
20. Label the specimen to indicate specimen before and after
histamine injection
21. Comfort the patient
22. Clean or discard used equipment's.
23. Record

Gastric Gavage
Objective: at the end of this lesson, the learner will be able
to:-
1. Define gastric gavage.
2. List the purpose of gastric gavage.
3. Collect the necessary equipment for gastric gavage.
4. Perform the gastric gavage according to the steps.

Gastric Gavage CON.
Definition: Gastric gavage is providing nutritional supplement

when the patient is unable or not willing to take food per
mouth with normal GI tract functioning.
A feeding given into the stomach by a tube passed through the
nose

Purpose
1. To provide total supplemental nutrition

2. Restore fluid, electrolyte and acid base balance.
3. Reduce or eliminate catabolism and negative nitrogen
balance.
4. To administer medication
Precaution
Severe pancreatitis
Enterocutaneous fistulae
GI ischemia

Indications
Gastrointestinal diseases and surgery.
Hyper metabolic states (burns, multiple trauma, sepsis,
cancer)
Certain neurologic disorders (stroke and coma)
Following certain types of surgery (head and neck,
esophagus)
For patient who
Loss their consciousness
Laryngeal operation
Oral operation
Confusion or delirium.

Contra indication
Diffused peritonitis
Intestinal obstruction that prohibits normal bowel
functioning
Intractable vomiting; paralytic ileus
Severe diarrhea

Equipment
NG tube
Tap water
Formula /Liquid food ( at room temperature)
IV stand
Tray
Clean Glove
50ml syringe
Funnel
Disposable gavage bag and tubing
Towel
Tissue paper
Dirty receiver
Chart
Procedure
1. Explain the procedure to the patient, provide privacy
2. Wash hands and assemble the necessary equipments.
3. Assist the client to a fowler's position in bed or a sitting position in a
chair, the normal position for eating
If this position is contraindicated, a slightly elevated right side lying
position is acceptable. These position help/ enhance the gravitational
flow of the solution & prevent aspiration.
4. Assess the client for feelings of abdominal distension, blenching, loose
stools, flatus or plain; bowel sounds and allergies to foods.
5. If NG tube is not in place follow the NG tube insertion procedure and
insert the tube and secure it.
6. Confirm correct placement of the tube

Procedure CON
7. Cover the patients chest with the towel to protect him/her from spills of
food.
8. Aspirate stomach contents to determine amount of residual and measure
it. If the residual is over 50-100 ml in adults and 10 ml or more infants, hold
the feeding until residual diminishes or subtract the withdrawn amount
from the total feeding and administer the rest. All these are based on the
policy agency.
9. Reinstall the gastric contents to the stomach to prevent electrolyte
imbalance.
10. Before the feeding solution has drained from the neck of the bottle,
instill 50-60 ml of water through the tube, to prevent further blockage.
11. Remove air from the feeding tubes and attach it to the nasogastric tubes
and to prevent air from entering to the stomach, never allow the syringe or
the gavage bag to empty completely.
Procedure CON
12. Hang bottle on IV stand beside patient and run the food through the giving set or if a
syringe is to be used remove plunger from barrel of syringe and attack barrel to nasogastric
tube.
13. Deliver feeding over the desired length of time (as ordered). Usually 200-350 ml over 10-15
minutes is given.
14. After the administration of the appropriate amount of food, flush the tube by adding about
60ml of water to the syringe. This maintains the patency of the tube by removing excess food
particles which could block the tube.
15. If you are administering a continuous feeding, flush the tube every 4hours to help prevent
tube occlusion.
16. To discontinue the NG tube feeding disconnect the syringe from the feeding tube.
17. Close the tip of the NG tube with its plug cap before all of the rinse solution has run
through to prevent leakage and contamination.
18. Leave the patient in semi sitting position of slightly elevated right lateral position for at
least 30minutes.
19. Communicate with your patient.
20. Clean and return used equipments.
21. Wash your hand
22. Record the amount given and the patients general condition.

Complications
Diarrhea due to hyper osmolar feeding, rapid infusion, bacteria
contaminated feedings, lactase deficiency and food allergies etc.
Nausea/ vomiting- due to Change in rate of feeding, offensive
smell, in adequate gastric emptying.
Cramping/ gas- due to air in tube.
Constipation- high milk content, low fiber intake, inadequate fluid
intake.
Aspiration pneumonia- due to improper tube placement, flat in
bed, too large tube etc.
Tube displacement- due to excessive coughing/ vomiting, tracheal
suctioning etc.
Tube obstruction- due to inadequate flushing/ formula rate.
Naso pharengeal irritation- due to tube position and large tubes.
Hyper glycaemia- glucose intolerance and high carbohydrate
feeding content.

CON.
Gastrointestinal complications
Diarrhea (most common), Nausea/vomiting,
Gas/bloating/cramping, Dumping syndrome and
Constipation
Mechanical
Aspiration pneumonia, Tube displacement, Tube obstruction
and Nasopharyngeal irritation
Metabolic
Hyperglycemia, Dehydration and azotemia (excessive urea in
the blood) and Tube feeding syndrome

Removal of a Nasogastric Tube
Objective: at the end of this lesson, the learner will be able to:-
1. Define Nasogastric Tube removal.
2. Collect the necessary equipment for Nasogastric Tube
removal.
3. Perform the Nasogastric Tube removal according to the
steps.

CON
Definition: Nasogastric Tube removal is the process of

withdrawing the nasogastric tube which was placed in
clients stomach for different purpose.
When the physician determines that the clients nutritional
status no longer warrants EN therapy or the need to provide
decompression of the gastric contents, the nasogastric tube
is removed. If the client is connected to suction for
decompression, the physician may prescribe clamping the
tubing for several hours prior to removal, to ensure a
functioning GI tract.

Equipment:
1.Tube plug or clamp,

2.Towel, washcloth,
3. Paper towel,
4. Receptacle for contaminated items,
5. Don sterile gloves.

Procedure
1. Hand wash
2. Verify the physicians prescription.
3. Check the clients armband and explain the procedure.
4. Provide for privacy.
5. Wash hands and don gloves.
6. Place the client in a high Fowlers position and adjust the height of the
bed to a comfortable working position.
7. Place the towel across the clients chest.
8. Clamp or plug the tube and unpin the tube from clients gown.
9.Remove the tape securing the tube from the clients nose.

CON.
10. Hold the paper towel open in your non dominant hand
under the clients chin; with your dominant hand, grasp and
pinch the tube near the nostril, and remove the tube with a
steady, continuous pull, allowing the tube to fall into the paper
towel.
11. Dispose of the tube and paper towel in the receptacle.
12. Clean the clients nares and provide oral hygiene.
13. Position the client comfortably, place call light in easy
reach, and return bed to a low position.
14. Remove gloves, place in receptacle, and dispose of
receptacle in accord with agency policy.
15. Wash hands and document procedure in the clients
medical record
CHAPTER-TWO :Urinary Catheterization
Learning objective:
At the end of the lesson, the students will be
able to:-
1. Define urinary catheterization
2. List the purpose of urinary catheterization
3. Identify the necessary equipment for
catheterization
4. Perform procedure of urinary catheterization
Urinary Catheterization con..
Urinary catheterization:- is introduction
of a tube (catheter) through the urethra
into the urinary bladder.
Is performed only when absolutely
necessary for fear of infection and
trauma.
Note: - strictly a sterile procedure i.e. the
nurse/H.W/ should always follow aseptic
technique

Indications of urinary catheterization
To relieve urinary retention or incontinence
To obtain sterile urine specimen
To measure the amount of post void residual
urine for monitoring
To empty the bladder before, during and after
surgery.
In case of bladder obstruction
For a patient with neurologic disorders
(unconscious patients)
For bladder irrigation or decompression
Purpose
To empty the bladder in case of retention of urine,
occurring as a post operative complication
In case of retention due to injury or tumor of the
spinal cord
In case of obstruction due to the blockage of the
urethra causing stricture
To obtain sterile specimen of urine
To ensure that the bladder is empty before an
abdominal or pelvic operation or Paracenthesis
To keep incontinent patient dry

Purpose con
To avoid contamination after
operation of vagina or perineum
To empty bladder irrigation or
instillation of the bladder
To determine if residual urine is
present in the bladder
To facilitate healing of urethra

Types of catheter
Categories of urethral
catheters
1. Straight or Robinson catheter a single
lumen tube
2. Retention or Foley catheter ,contains
second lumen ( two and three way
catheter)
3. Coude (elbowed):- used for elderly
men who have BPH- which is curved
tip
Types of Catheterization (routes)
1. Urinary catheterization
2. Supra-pubic catheterization

Catheters can also differ in the number
of lumens they have
1. Straight catheter -has single lumen
2. Double lumen catheter- has two lumens
3. Triple lumen catheter has three lumens.
In double lumen catheter, one lumen is used
to inflate balloon at the end of the catheter
and the other lumen is to drain urine.
The triple lumen catheter provides an
additional lumen for the instillation of
irrigating solutions.
Catheter size depends on the size of
the urethral canal
A. #8-10fr_ children
B. #14-16fr_ female adults
C. #18fr adult male

Catheter may be made of
Select appropriate balloon size
5-10ml _for adults
3ml_ for children.
Determine appropriate catheter length
by the client gender
For adult male _ 40cm catheter
For adult female_ 22cm catheter

Catheterization using a straight or plain,
Intermittent catheter for female

Catheterization using a straight or plain,
Intermittent catheter for female
Definition:-introducing plain or straight catheter
through the female urethra to the urinary
bladder
Purpose
To relieve discomfort due to bladder distention
To obtain a sterile urine specimen
To empty the bladder prior to surgery
is used to drain the bladder for shorter
period of time (5-10min).
Equipment Sterile
1. Sterile plain catheter rubber or plastic
2. A bowl for antiseptic
3. Gauze
4. Sterile towel(3#)
5. forceps 3#
6. Sterile Glove
7. Kidney dish
8. Sterile urine specimen container if needed
9. Sterile receiver
10. Lubricant (water based jelly or xylocaine jelly)
Clean
1. Rubber and draw sheet
2. Antiseptic solution
3. Clean Glove
4. Measuring jug
5. Flash light
6. Screen
7. Specimen form
9. Receiver
Procedure
1. Explain procedure to the patient
2. Screen the bed
3. Wash hands
4. Turn blanket and bedspread down to foot of bed
5. Turn top linen up wards to the patients chest to
protect form complete exposure.
6. Place patient in dorsal recumbent position with the
knees flexed and thigh apart then
7. Put rubber and draw sheet under buttocks, cover
patient with the linen(if patient soaked use
examination glove)

Con.

Procedure con..
8. Apply disposable glove
9. Clean starting from mid thigh with clean warm water
and soap and dry the area
10. Open sterile filed
11. Done sterile gloving
12. Create a sterile field and Drape the client with a
sterile drape (bottom far side, near side, pubic area)
13. Prepare the equipment and Put receiver for urine
near the genital area
14. Place sterile equipment on drape between patient
tight
Con.

Procedure con..
near the vulva.
16. Use non dominant hand to separate labia until the
catheter is inserted
17. Wash the outer skin folds then inner labia and
urethral meatus with antiseptic solution from front to
back. (Starting from outer proceeding to inside)
18. Put forceps in the receiver kidney dish
19. Wash and Rinse the area well from outer skin folds
then inner labia and urethral meatus finally with distil
water from front to back.
Procedure con..
23. Lubricate the insertion tip of the catheter (5-
7 cm in)
24. Expose the urinary meatus adequately by
retracting the tissue or the labia minora in an
upward direction
25. Gently insert the catheter into meatus until
urine is noted. Continue inserting for 2.5 to 5cm
additional.
26. Remove catheter after desired duration or all
expected urine expelled
Procedure con..
27. Measure urine, dry area with dry
gauze, remove bed protection
28. Position patient comfortable and cover
29. Remove and clean equipment
30. Send specimen to the laboratory
31.documentation

Male plain or straight urinary catheterization

Male plain or straight urinary
catheterization
Definition: - Introducing plain
or straight catheter through
the male urethra to the
urinary bladder

Equipment Sterile
1. 2 Sterile plain catheter rubber or plastic
3. Cotton swab
4. Gauze
5. Large sterile fenestrated towel
6. Sterile towel
7. forceps ( 3 )
8. Sterile receiver
9. Kidney dish
10. Lubricant (water based jelly or xylocaine jelly)
11.Sterile urine specimen container if needed
12. Sterile Glove

Clean
3. Receiver
4. Measuring jug
5. Flash light
6. Screen
7.Specimen forms
8. Clean Glove
Procedure

Procedure
2. Screen the bed
3. Wash hands
4. Turn top linen up wards to the patients Umbilicus and blanket
and bed spread up to mid-thigh.
5. Assist patient into supine position with legs spread
and feet together
6. Wash the perennial area with warm water and soap
7. Wash hands
8. Open sterile field
9. Put on sterile gloves
10. Place sterile towel under the patient and fenestrated towel
over the patient thigh
Procedure con
11. Prepare antiseptic swabs and Pick up
penis with non-dominate hand protract
foreskin if not circumcised, grasp directly
behind glans and spread meatus between
forefingers and thumbs.

Procedure con
12. Cleanse penis using circular motion, starting over meatus and
working down wards glans, repeat procedure twice using new
swabs always by the help of forceps.
13. Pick up catheter, lubricated at least from 8-10cm distal end.
Draw penis upwards and forwards at 90 angle to the leg insert
the catheter, lower penis when feeling resistance at an angle of
60 degree
14. Insert catheter about 18-20cm till urine flow
15. Remove catheter, replace foreskin to avoid complication
16. Remove catheter measure urine, dry area with dry cotton
swab, remove bed protection position patient comfortable and
cover
17. Remove and clean equipment
18. Send specimen to the laboratory
Insertions of indwelling catheter for
Female patient
Leaning objective:
At the end of the lesson, the learner will be
able to
1. Define indwelling catheter for female pt
2. Identify equipments for insertions of
indwelling catheter
3. Demonstrate insertions of indwelling
catheter
Insertions of indwelling catheter for
Female patient con
definition: Introduction of the indwelling
catheter through the female urethra in the
bladder
Purpose
prevent retention by use of an indwelling catheter
To prevent frequent catheterization in case
where pt is unable to pass urine
To prevent bed sore in case of urine incontinence
To prevent infection in cases of perineal
operation
Equipment Sterile
1. Indwelling catheter rubber or plastic
3. Cotton swab
4. Gauze
5. Large sterile fenestrated
towel
6. Sterile towel
7. Forceps ( 3)
8. Sterile receiver
9. Kidney dish
10. Syringe
11. Sterile water
12. Lubricant
Clean
3. Receiver
4. Urinary drainage bag
5. Screen
6. Adhesive plaster

Procedure
1. Explain procedure to client and Provide for privacy
2. Set the bed to a comfortable height to work,
and raise the side rail on the side opposite you.
3. . Place patient in dorsal recumbent position
with the knees flexed and thigh apart then
4. Drape clients abdomen and thighs.
5. Ensure adequate lighting of the perineum.
6. Wash hands, don disposable gloves, and wash
perineal area from the mid thigh.
7. Remove gloves and wash hands
Procedure con
8. bring urine collection bag ready for attaching near to side of
bed
9. Done sterile gloving
10. Create a sterile field and Drape the client with a
sterile drape (bottom far side
nearside ,pubic area)
11. Prepare the equipment and Put receiver for urine near the
genital area
12. Place sterile equipment on drape between patient tight
near the vulva.
14. Use non dominant hand to separate labia until the
catheter is inserted
Procedure con
15. Wash the outer skin folds then inner labia and urethral
meatus with antiseptic solution from front to back. (Starting
from outer proceeding to inside)
17. Wash and Rinse the area well from outer skin folds then
inner labia and urethral meatus finally with distil water from
front to back.
19. Dry the dry gauze the outer skin folds then inner labia and
urethral meatus from front to
back
21. Lubricate the insertion tip of the catheter (5-7 cm in)
Procedure con
22. Expose the urinary meatus adequately by retracting
the tissue or the labia minora in an upward direction
23. Gently insert the catheter into meatus until urine is
noted. Continue inserting for 2.5 to 5cm additional.
24. After catheter insertion, the balloon is inflated to
hold the catheter in place within the bladder.
25. Instruct the client to immediately report discomfort
or pressure during balloon inflation;
if pain occurs, discontinue the procedure, deflate the
balloon, and insert the catheter further into the
bladder

Procedure con
26. Gently pull the catheter until the retention balloon
is snuggled against the bladder neck (resistance will be
met) re-push back 2cm after the test
27. If laboratory test is prescribed, collect some
amount of urine in the sterile specimen bottle straight
from the catheter
28. Secure the catheter to the abdomen or thigh and
connect to drainage tube
29. Place the drainage bag below the level of the bladder.
30. Remove gloves, dispose of equipment, and wash hands.
31. Help client adjust position
32.Assess and document
Insertions of indwelling catheter
for male pt
Objective:- At the end of the lesson, the
learner will be able to
1. Define insertions of indwelling catheter
2. Identify the necessary equipment for
insertions of indwelling catheter
3. Demonstrating the procedure of
indwelling catheter

Con
Definition: -introductions of indwelling
catheter through the male urethra in to the
bladder
Purpose
To prevent retention by use of an indwelling
catheter
To prevent frequent catheterization in case
where pt is unable to pass urine
To prevent bed sore in case of urine
incontinence
To prevent infection in cases of perineal
operation It has a balloon
Equipment Sterile
1. Indwelling catheter rubber or plastic
3. Cotton swab
4. Gauze
5. Large sterile fenestrated towel
6. Sterile towel
7. Forceps ( 3 )
8. Sterile receiver
9. Kidney dish
10. Syringe
11. Sterile water
12. Lubricant(water based jelly or xylocaine jelly)
13. Sterile urine specimen container if needed
14. sterile Glove

Equipment Clean
3. Receiver
4. Urinary drainage bag
5. Screen
6. Adhesive plaster
7.clean Glove
Procedure
2. Screen the bed
3. Wash hands
4. Turn top linen up wards to the patients chest
to protect from complete exposure.
5. Assist patient into supine position with legs
spread and feet together rubber and draw sheet
under buttocks, cover patient with the linen
6. Wash the perennial area with warm water
and soap
Procedure con.
7. Wash hands
8. Prepare sterile trolley
9. Uncover patient,
10. Put on sterile gloves, place sterile towel under the
patient and fenestrated towel over the pt thigh
11. Test balloon before insertion on sterile filed with
recommended amount of sterile water
12. Prepare antiseptic swabs and Pick up penis with
non-dominate hand retract foreskin if not circumcised,
grasp directly behind glans and spread meatus between
forefingers and thumbs.

Procedure con.
13. Cleanse penis using circular motion, starting over meatus and
working down wards glans, repeat procedure twice using new
swabs always by the help of forceps.
14. Pick up catheter, lubricated at least 7.5cm from
distal end. Draw penis upwards and forwards at 90
angle to the leg insert the catheter, lower penis when
feeling resistance at an angle of 60 degree
15. When catheter is inserted, inflate the balloon with 5-15ml as
indicated on catheter
16. Pull gently on the end of the catheter to be sure it
will not leave the bladder then push back 2cm to
relieve pressure from sphincter
17. Attach drainage tube to catheter and drainage bag
Procedure con.
18. Tie tube and drainage bag to the
bed ,put the bottle below the patient
level
19. Cover and comfort the patient
20. Return the equipment

Applying a Condom Catheter
Objective:- at the end of this lesson, the
learner will be able to
1. define condom catheter
2. describe the purposes of condom
catheter
3. apply condom catheter by following
the steps
Con
Definition:- The condom catheter is an
external drainage system to collect urine
from male clients who have incontinence
Purpose
Provide a means of collecting urine and
controlling incontinence without the risk
of infection that an indwelling urinary
catheter imposes
Equipment
Condom catheter kit with adhesive
strip
Urinary drainage bag/bed pan
Clean gloves
Basin with warm water and soap
Towel and wash cloth

Procedure
1. Wash hands and apply gloves.
2. Select an appropriate condom catheter.
3. Cleanse the penile shaft.
4. Inspect the penile shaft for excessive hair.
5. Inspect the penis for altered skin integrity.
6. Stretch the shaft of the penis and un roll the condom to the
base of the penis.
7. Follow product directions for the application of the sealant
8. Attach the condom to the drainage apparatus,
9. either a leg bag or bedside drainage bag.
10. Remove gloves and wash hands.
11. Remove and reapply the condom catheter every 24 to 48
hours, or when leakage occurs.
Contraindication of catheterization
Urethral trauma
Pelvic fracture
Scrotal hematoma

Complications of catheterization
Urethral trauma from friction

during insertion
Infections(renal inflammation,
pyelonephritis, cystitis, etc) from
ascending infection following the
catheter
Bladder Irrigation (open and closed method)
Objective: -at the end of this lesson, the students will able to :
1.Define bladder irrigation
2.Demonstrate bladder irrigation

Con
Definition: -it is the washing out of the bladder to clear the catheter
and/or the bladder.
Purpose
To clean the bladder before operation depending on the surgeons order
To arrest bleeding from the bladder
To clean the catheter from mucous or blood clots
To clean bladder form pus
ways of irrigating catheter or bladder.
1.Closed intermittent or continuous irrigation (irrigating through a three
way catheter).
2. Irrigating through catheter after separating the catheter and tubing (open
intermittent system).
Amount of solution to be used is
1000ml -adult bladder
200ml children bladder catheter irrigation.
Con
Precaution
Care should be taken not air into the balder as it may cause spasm
Not more than 100-300ml must be instilled at a time after bladder
operation capacity may be limited.
If the catheter is blocked by blood clots, a suction of the catheter must
be proceed the irrigation

Equipment
a complete set to catheterization

A sterile bladder syringe for open method
Irrigation solution e.g. normal saline or cold solution to stop bleeding
Irrigation solution in a beg, infusion set, Y-piece, urine drainage tube and
bag clamp for closed method
Receiver with plaster to put the catheter end (open method)
Rubber and draw sheet
clamp
pail
glove

Procedure for open method
1. Insert catheter as in catheterization
2. If catheter is already in the bladder
3. Put bed protection
4. Draw solution in the syringe
5. Clamp catheter, attach syringe in the catheter, place drainage tube on a
swab
6. Decamp instill the solution gently into the bladder
7. With draw syringe, put end of catheter on the receiver which is placed
on the bed protection
8. Repeat this procedure 2-3 times or more until the return solution is
clear
9. Clean catheter and drainage tubing with a swab and connect it again

Closed method
1. Prepare solution bag with IV set

2. Connect Y-place to the catheter and IV set to one end of the Y and
drainage tube to the other end
3. Intermittent irrigation clamp the drainage tube and let irrigation
solution run in the bladder (100-200ml) then close the set and open the
drainage tube empty the bladder.
4. Repeat this procedure as soften as necessary
5. Empty the collection bag frequently
6. Subtract the irrigation solution form the total urinary output if balance

Suprapubic catheter care
Definition: -A Suprapubic catheter is
inserted through the abdominal wall
above the symphysis pubis into the
urinary bladder.
Purpose
to prevent bladder infection
To keep skin integrity

Con.
Care of clients with Suprapubic catheter include
Regular assessment of the clients urine, fluid
drainage system.
Skin care around the insertion site involves sterile technique.
Periodic clamping of the catheter preparatory to
removing it and measurement of residual urine.
Leaving the catheter open to drainage for 48to 72
hours then clamping the catheter for 3 to 4 hour
periods during the day the client can void
satisfactory amounts.
Dressing should be changed whenever they are soiled.
A small amount of iodine is used.
Catheter removal
Withdraw the solution or air from the balloon using a
syringe and remove gently.

CHAPTER THREE:-Enema
Objectives: - After completing this lesson, the
students will be able to
1. Define enema
2. Identify different types of enema
3. Demonstrate different types of enema
4. Demonstrate insertion of flatus tube

Enema Con.
Definition: -is the introduction of fluid into rectum
and sigmoid colon for cleansing, therapeutic or
diagnostic purposes.

Enema Con
Purpose:
For emptying- Soap solution enema
For diagnostic purpose- (Barium enema)
For introducing drug/substance - (retention enema)
Solution used:
Normal saline
Soap solution - sol soap 1gm in 20ml of H2O
Epsom salt 15gm-120gm in 1000ml of H2O

Mechanisms of some solutions used in
enema
Tap water: -
increase peristalsis by causing mechanical distension of
the colon
Soap solution:-
increases peristalsis due to irritating effect of soap to the
luminal mucosa of colon.
Epsom salt:-
causes flow of ECF(extra cellular fluid) to the lumen
causing mechanical distension resulting peristalsis
Normal saline solution:-
Dilates, stimulates and irritates bowel

Classification
1. Cleansing(evacuation)
2. Retention
3. return flow enema
4. Passing flatus tube

1. Cleansing enema
A. High enema
is given to clean as much of the colon as possible
The solution container should be 30-45 cm about the rectum
B. Low enema
is administered to clean the rectum and sigmoid colon only

Con..

Guidelines
Enema for adults are usually given at 40-43 OC and children
at 37.7OC
Hot-cause injury to the bowel mucous
Cold- uncomfortable and may trigger a spasm of the
sphincter muscles
The amount of solution to be administered depends
on:
Kind of enema
The age of the person and
The personal ability to retain the solution

Amount of solution
Age Amount
<18months 50-200ml
18mont-5yrs 200-300ml
5-12 yrs 300-500ml
12yrs and older 500-1000ml
size
The rectal tube should be appropriate: is measured in French scale
Age Size
Infants/small child 10 -12fr
Toddler 14 -16fr
Scholl age child 16 -18fr
Adults
8/8/2017 22-30fr
FUNDAMENTAL OF NURSING BY DEJEN G.
Purpose
To stimulate peristalsis and remove feces or
flatus(for constipation)
To soften feces and lubricate the rectum and colon
To clean the rectum and colon in preparation for an
examination. E.g. colonoscopy
To remove feces prior to surgical procedure or
delivery
For incontinent patients to keep the colon empty
For diagnostic test E.g. Before certain x-ray exam-
barium enema
Before giving stool specimen for certain parasites
Types of liquid used for cleansing enema
1. Tape water = 500 to 1000 cc
2. Soap solution= 500 to 1000 cc
3. Normal saline - made by mixing one teaspoon of
salt in a liter of water usually contain 1000cc of
normal saline.
4. Epsom salt= 15 gm - 120 gm in 1000 cc of water

Precautions
No need to use too much soap - this may produce
sever irritation of the membrane of the colon.
Tap water must be administered consciously for
infants or adults who have altered kidney or cardiac
reserve this is to avoid water intoxication.

Contraindications
Rectal surgery
Rectal /anal/ cancer
Rectal infection
for a patient with appendicitis
Rectal /Anal/ fissure

Equipment
1. Container for solution
2. Solution at temperature for adult 40-43 0c
3. Bath thermometer for infant (37.7 0c)
4. Water proof material /mackintosh/
5. Screen, bath blanket, towel
6. Enema cane with tube
7. Gauze to apply lubricant /swab/
8. Bed pan and toilet tissue
9. IV pole/stand
10. Gloves
11. Receiver /kidney dish/
12. Lubricant
13. Rectal tube /catheter /
14. Clamp, connector, funnel

CLEANSING ENEMA

Procedure
1. Great and Inform the patient about the procedure.
2. Put bed side screen for privacy.
3. Attach rubber tube with enema cane with
nozzle/syringe/ and stop cock or clamp.
4. Place the patient in the left lateral position with
the right leg flexed for adequate exposure of the
anus (facilitate the flow of solution by gravity in to
the sigmoid and descending colon which are on
the side).
5. Fill the enema cane with 1000cc of solution for
adults.
Procedure con..
6. Lubricate about 5cm of the rectal tube facilitate
insertion through the sphincter and minimize trauma.
7. Hung the cane at least 45cm from bed or 30cm from
patient on the stand.
8. Place a piece of mackintosh under the bed
9. Make the tube air free by releasing the clamp and
allowing the fluid to run down little to the bed pan
and clamp to prevents unnecessary distention.
10. Lift the upper buttock to visualize the anus

Procedure con..
11.Insert the tube
7-10cm in adult smoothly and slowly.
5-7.5 cm in the child.
2.5-3.75cm in an infant.
12.Raise the solution container and open the clamp to
allow fluid to flow.
13.Administer the fluid solely. if client complains of
fullness or pain stop the flow for 30 second and
restart the flow at a slower rate

Procedure con..
14.Do not allow all the fluid to go as there is a
possibility of air entering the rectum or when the
client cannot hold any more and wants to defecate
15.Remove bed pan clean the rectal tube.
16.Document the procedure.
Note
If resistance is encountered at internal sphincter,
ask the clients to take a deep breath then run a
small amount of solution (relaxes the internal anus
sphincter)

2.Retention Enema
Objectives:- At the end of this lesson, the students
will be able
To define retention enema
To identify the necessary equipment's
To Perform retention enema

Retention Enema con
Definition: -Administration of solution to be

retained in rectum for short or long period
The fluid usually medicine is retained in rectum for
short or long period- for local or general effects
E.g. oil retention enema, antispasmodic enema

Antispasmodic enema
Principles:-
is given slowly by means of a rectal tube
The amount of fluid is usually 150-200cc
Cleansing enema is given after the retention time is
over
Temperature of enema fluid is 37.4 c or body temp

Purpose
To supply the body with fluid
To give medication E.g. stimulants(par-aldehyde) or
antispasmodic
To soften impacted fecal matter.
Other equipment is similar except the tube for
retention enema is smaller in width.

Con
Procedure of retention enema
Similar with the cleansing enema but the enema should
be administered very solely and always be preceded by
passing a flatus tube
Note
Most medicated retention enema must be
preceded by a cleansing enema/flatus tube
Elevate foot bed to help patient retain enema.
Kinds of solution used are plain water, normal
saline, glucose 5% , soda bicarbonate 2-5%.
Olive oil 100-200cc to be retained for 6-8 hours
is given for sever constipation.

3.Rectal washout (siphoning enema
Objectives:- At the end of this lesson, the students will be able

1. To define rectal wash out
2. To identify the necessary equipment's
3. To Perform rectal wash out

Rectal washout (siphoning enema) Con.
Definition: - is the injection of a liquid in to the

rectum to be wash out the rectum and colon.
-Called Colon irrigation or colonic flush
-lso called enterolysis
or -is the process of introducing large amount of
fluid in too large bowel for flush in purpose and allow
return or wash out fluid

Purpose
To prepare the patient for x-ray exam and
sigmoidoscopy.
To prepare the patient for rectum and allow
return or wash out fluid

Con
Precaution
The rectal wash out should not exceed for more than 2 hours
The rectal wash out should be finished 1 hour be for
examination (e.g. x-ray, sigmoidoscopy) this is to give time
for the large intestine to absorb the rest of the fluid
Give cleansing enema 1/2 hour befor the rectal wash out.

Solution Used
1. Normal saline
2. Soda-bi-carbonate solution(to remove excess
mucus)
3. Tap water
4. KMNO4 sol. 1:6,000 for dysentery or weak tannic
acid
5. Tr. Asafetida in 1:1,000 to relieve distention

Equipment for rectal washout
1. Pitcher
2. News paper
3. small jug
4. Large mug for fluid
5. Bucket
6. Funnel
7. Bedpan
8. Tubing and glass connecting
9. Rectal tube or catheter and clamp
10. lotion thermometer
11. Mackintosh and towel
12. swab and Vaseline
13. Solution of (40 oc )
14. glove
Procedure
1. Great and Explain the purposes of the procedure
to patient
2. Prepare the ordered solution
3. Bring equipment to bedside
4. Screen the bed and place the patient in the left
lateral position with the buttocks on the edge of
the bed
5. Place the mackintosh and towel underneath the
buttocks
6. Check the temperature of the fluid and fill the
small jug

Procedure con
7. Lubricate the catheter
8. Run the fluid through to expel air and clamp it.
9. Expose the anal region separate the buttocks, with
one hand and insert the rectal tube in to the rectum
8-10 cm
10. Open the clamp and allow to run about 100 cc of
fluid in the bowl, then siphon back in to the bucket.

Procedure Con.
11. Carry on the procedure until the fluid returned is
clear
12. Remove the catheter and leave the patient
comfortable
13. The amount returned should be measured to
ensure that none has been retained
14. Record or chart the time, result and effect on the
patient

Note
The procedure should not take >2 hours.

Should be finished 1 hour before exam or x-ray
to give time for the large intestine to absorb the
rest of the fluid.
Give cleansing enema hour before the rectal
wash out
Allow the fluid to pass slowly
Amount of solution 5-6 liters until the wash out
rectum fluid becomes clear.
4.Inserting a rectal tube
Objective- at the end of this lesson, the students will be able
to
describe fecal impaction
describe the necessary equipment for removal of fecal
impaction
demonstrate removal of fecal impaction

Inserting a rectal tube Con
Definition: The insertion of a rectal tube is done
to manage flatulence (gas) following abdominal
surgery and/or reduce abdominal distention due to
flatulence.
Purpose
It can be used to alleviate abdominal distention.
It is used to control diarrhea that cannot be
controlled with medical management and/or the
use of rectal pouches, pads, or diapers due to
extensive skin breakdown

Equipment
1. Rectal tube or catheter, 22 to 30 French
2. Water-soluble lubricant
3. Bed side drainage bag (optional, if rectal tube used
to manage diarrhea)
4. Ostomy odor eliminator or similar product
(optional)
5. Clean gloves
6. Disposable pads or towels

Procedure
1. Great and Explain procedure to client , Explain
rationale regarding need of tube and its short
duration of use.
2. Collect the necessary equipment
3. Wash hands.
4. Assemble equipment.
5. Position client in left lateral position with upper
leg bent over lower leg

Procedure con.
6.Place disposable pads (if not available, use towels).
7. Use odor eliminator per manufacturer (optional).
8. Apply gloves.
9.Apply lubricant to a gloved finger.
10.Insert lubricated finger into rectum to check for
possible obstructions prior to insertion of rectal tube
11.Change gloves if soiled from rectal exam.
12.Lubricate end of catheter

Procedure con.
13.Gently insert catheter into anal canal
approximately 1015 cm (46 inches)
14.Attach plastic bag or drainage bag to end of
catheter if needed to control odor or stool
15.Inflate balloon of catheter or tape tube to the
lower buttock if rectal tube is not to be removed
within 30 minutes
16.Dispose of pad. Remove soiled gloves and place in
appropriate receptacle.
17.Wash hands
18.Document
QUZI
1. Write the Mechanisms of Normal saline , Epsom
salt, Soap solution, Tap water solutions used in
enema?
2. Write the Precautions when using CLEANSING
ENEMA and Rectal washout (siphoning enema)?
3. write Principles of Antispasmodic enema?

CHAPTER-FOUR:-Nursing process
Learning objectives:-At the end of this session the
students will be able to:
Describe the nursing process
Identify characteristics of nursing process
Discuss the phases of nursing process
List the benefit of nursing process
Perform proper documentation by using the nursing
process

Nursing process con
Definition:-The nursing process is a systematic,
patient centered, goal oriented methods of caring
that provides frame work for nursing practice.
Nursing is independent scientifically based and
creative required knowledgeable component and
independent profession.
It is a systematic problem solving approach to client
care.
It is a series of planned steps and actions directed
toward meeting the need and solving problems of
people and their significant others

Characteristics of Nursing Process
1.Systematic:-
each nursing activity is a part of an ordered sequence of activities.
Each activity depends on the accuracy of the activity that
precedes it & influences the action that follows it.
2.Dynamic:-
no one step in nursing process is a onetime phenomenon.
There is Overlapping and interaction among steps in some nursing
situations, all five stages occur almost simultaneously.
3.Interpersonal:-
nursing process insures that nurses are patient centered rather
than task centered. Always at the heart of nurse is human being.
The nursing process encourages nurses to work together to help
patient use their strengths to meet all their human needs.

Characteristics of Nursing Process Con..
4. Goal oriented:-
nursing process offers a means for nurses & patients to work
together to identify specific goals to determine which goals
are the most important to the patient and to match them
with appropriate nursing action.
5. Universally applicable:-
the nursing process offers direction for all the activities
carried out by the nurse when caring for well or ill, any age
at any practice setting.

Benefits of nursing process
When used well, the nursing process achieves for
the patient
scientifically based holistic individualized care
provides opportunity to work collaboratively with
other nurses
provides continuity of the patients care
nurses who use nursing process achieves a clear and
efficient plan of action by which they process can
achieve the best results for the patients.

Documenting the nursing process
The ability to communicate clearly in writing is a
critical nursing skill.
Accurate, concise, timely & relevant
documentation provides all the members of the
care giving team with a picture of the patient.
Legally speaking, a nursing action not documented
is not performed

Components of the Nursing Process

Components of the Nursing Process Con

1. Assessment
It is the first phase of nursing process.
is the systematic & continuous collection,
validation, & communication of patient data.
Data (information)-reflects how health function is
enhanced by health promotion or compromised by
illness.
Database: - includes all pertinent patient
information collected by the nurse. This enables a
comprehensive and effective plan of care to be
designed and implemented.
Data collection is a vital step in nursing process
because the remaining step depends on the
assessment data.
Assessment CON
Nursing assessments focuses on the patients
response to health problems
Data collection takes place during every
nurse patient interaction.

Types of data
there are two types of data.
1.Subjective (covert data) or symptoms;
Data that are not verified by other person include
the patients feeling and statements about his or her
health problems
Obtained through interview ,listening, and
observation skills.
It should always be taken by the patient own words
E.g. I get sharp pain in my chest.
nausea,
8/8/2017
headache,FUNDAMENTAL
abdominal pain .
OF NURSING BY DEJEN G.
Types of data- con
2.Objective data (overt data or sign):-
observable& measurable data.
Can be verified by other person.
Obtained through observation and physical assessment
techniques.
It is an information witnessed by the examiner E.g. E. g Bp,
RR, abnormal heart or lung sound
vital sign

Methods/skills / of data collection
1.Observation
is an assessment tool that relies on the use of the five
senses (sight, touch, hearing, smell and taste) to discover
information about client.
ability to observe and identify problems
2.Health interview(history taking):
the ability to communicate with others.
the health interview is a way of soliciting information from
the client. This Interview may also be called a nursing
history.

Methods/skills / of data collection con
3.Physical examination (Analysis of data)
is included as part of the assessment.
Analysis of bodily function using techniques of inspection,
palpation, percussion & auscultation.
For those who wish to emphasize its importance analysis
may be identified as a separate step of the nursing process.

The four physical examination techniques:
1. Inspection:-
the act of systematic and deliberate visual observation to
determine the functional status of body parts.
2. Palpation:-
the act of touching and filling body parts with hands in order
to determine texture, temperature, moisture, motion and
consistency of structures.
3. Percussion:-
the act of tapping a portion of the body to elicit sounds that
vary with the density of the underlying structures.
4. Auscultation:-
the act of listening for various sounds
PHYSICAL ASSESSMENT

Purpose of nursing assessment
To establish base line data

To determine the patients normal function
To determine presence or absence of dysfunction
To determine patients strength

Steps of nursing assessment
A. Data collection :-
Compiling information about the patient
B. Validation:-
double checking, the process of confirming the
accuracy of assessment data collected e.g. I feel
hot check body temperature how is it?
C. Organizing (clustering data):-
use functional health pattern
D. Documentation of data:-
Recording data
Characteristics of data
I. Complete; all the patient data needed to

understand the patients health problem
should be identified.
II. Factual or accurate
III. Relevant

Sources of data
A. Primary Source:- is the most reliable
information obtained from the patient.
B. Secondary Sources:-information obtained
from: Support people& patient records,
Laboratory test

Reading Assignment
Approaches of history taking
A. Medical approach
B. Functional pattern approach
C. Application of Nursing process in patients with mental
illnesses

Comparison of Nursing process and Medical
Nursing process pprocessMedical process
Deals with two types of health problems Deals mostly with problems with
1,human response problems 2,problems with structure and function of organs or
structure and function of organs or systems systems
requiring physicians orders
Uses the five step approach and provides Uses the five step approach but has
strict rules for how each step is followed less precise rules for how planning ,
implementation and evaluation are
done.eg Goals are not clearly recorded
during planning
Considers the whole person ,organ and Mainly considers organ and system
system function ,as well as ,the persons function
response to organ/system malfunction
Focuses on teaching individuals or groups Focuses on teaching about how
how to be independent on activities of daily diseases and trauma are treated
living
Involve individuals ,their significant others Mostly involved with groups and
,and with groups in nursing care provision families
Types of Nursing Assessment
Depending on the clinical condition, patient status, time
valuable and purpose, it is classified into:-
1.Initial(admission) assessment:-
is performed w/n the patient is admitted to hospital.
Performed at the time the patient enters the health care
facility.
Very broad and leads us to a center of our diagnosis
The aim of initial assessment is collection of data concerning
actual or potential dysfunction.
Purpose:-
To establish a complete database for problem identification
and care planning.
To identify functional health patterns those are problematic
To evaluate the patient health status
Performed at the time the patient enters the health care
facility.
2. Focused Assessment
The nurse gathers data about a specific problem
that has already been identified.
It is concentrated on certain systems.
It leads us to the general condition of the specific
diagnosis.
Its aim is to determine status of a specific problems
identified during previous assessment
Purpose:-
to identify new or over looked problems
The nurse determines if the problem still exists
Weather the status of the problems has changed
3. Emergency assessment
When physiologic or psychological crisis presents or
takes place in life threatening situations where the
preservation of life is the top priority. E.g. ABCs
Assessment done on the life treating situation
This assessment should be fast, correct, and leading
to aggressive management.
Its aim is identification of life threatening situation

4. Time Lapsed assessment
is scheduled to compare a patients current status
to base line data obtained.
It is the final assessment done after a period of time
This assessment is focused type.
Its aim is comparing the patients current status to
baseline data obtained previously after an extended
period of time
Purpose:-
to evaluate any changes in patients functional
health
Performed when substantial periods of time have
elapsed between assessments.
Problems Related to Data collection
Inappropriate organization of the data base
Omission of relevant data
Commission of irrelevant data
Error of data
Failure to establish rapport and partnership
Failure to update database
Data Validation:-is the act of confirming or
verifying.
Purpose:-to keep the data from error, bias, or
misinterpretation

2. Nursing Diagnosis
It is the second phase of nursing process
To diagnose means to analyze assume information and drive
meaning.
A clinical judgment about individual, family or community
response to the actual or potential health problems (North
American Nursing diagnosis association/NANDA)
Is a statement that describes the human response (health
state or actual/potential altered interaction pattern) of an
individual or group that the nurse can legally identify and for
which the nurse can order definitive interventions to
maintain the health state or to reduce, eliminate, or prevent
alterations.

Difference between Nursing & Medical
Diagnosis
Nursing diagnosis
focuses on un healthy responses to health and illness,
Describes the patients response to the disease process. e.g.
Ineffective Airway clearance R/t tracheobronchial secretion
Medical Diagnosis
Describes the pathological process of disease.
identify diseases; describe a problem which directs the
primary treatment.
Medical diagnosis remain the same as long as the disease is
present e.g. Pneumonia

Steps of nursing diagnosis
Analyzing and interpreting data

Identifying client problem
Formulating Nursing Diagnosis
Documenting Diagnosis

Types of Nursing Diagnosis
1.Actual nursing diagnosis
describes a clinical judgment that the nurse has validated b/c of
the presence of major defining characteristics; problem is present
at the moment (experienced).
Describe human response to a health problem that is currently
being manifested.
Problem is present at the moment
Describes BY:- Problem +cause(Etiology)+defining
characteristics(S/S e.g
Deficient Fluid Volume related to nausea and vomiting as
manifested by dry skin and mucous membranes and decreased
oral intake of fluids
Ineffective Airway Clearance related to physiologic effects of
pneumonia as evidenced by increased sputum, coughing,
abnormal breath sounds, tachypnea, and dyspnea.

2.High risk nursing diagnosis/potential
describes a clinical judgment that an individual or group is more
vulnerable. Nurse determines that the patient is more vulnerable to
develop.
Is a clinical judgment that a person, family or community is more
vulnerable to develop the problem (potential problem)
Problem may occur/ unless measure is taken. No S/S or defining
characteristics
indicates the clients at risk for this response, although it is not yet
present.
It has only two parts:-Problem + etiology/Cause.

It has no defining characteristics.
E.g. .high- risk for impaired skin integrity related to advanced age,
immobility, confinement to bed
Risk for Infection related to presence of invasive lines
(intravenous line and indwelling bladder catheter)

3 .A Possible/probable Nursing Diagnosis
health problem is unclear and causative factor is unknown
problem may be present. The nurse suspects that a health
problem exists but need to gather more data to confirm the
diagnosis. has possible problem and factor. E.g. .possible
sexual patterns related to partners diagnosis of herpes
Possible Imbalanced Nutrition: Less Than Body
Requirements related to insufficient oral intake

4.Wellness Diagnosis
indicating a well response of the patient
clinical judgments about an individual, family, or community
in transition from it a specific level of wellness to higher
level of wellness
Diagnostic statements for wellness nursing diagnoses are
one- part, containing the diagnostic label.
e .g -Readiness for enhanced family process.
-Readiness for enhanced nutrition
Readiness for Enhanced Spiritual Well-Being

5.Syndrome:
comprises a cluster of actual or risk nursing diagnosis that is
predicted to present b/c of a certain situation or event.
Syndrome nursing diagnoses usually are one- part diagnostic
statements with the contributing factors contained in the
diagnostic label.

NANDA has five syndrome diagnoses
Rpe trauma syndrome.
Diseuse syndrome.
Post -trauma syndrome.
Relocation stress syndrome.
Impaired environnemental Interprtation
syndrome.

Purposes of the Nursing Diagnosis
1. Identifies nursing priorities

2. Directs nursing interventions to meet the clients high
priority needs
3. Provides a common language and forms a basis for
communication and understanding between nursing
professionals and health care team.
4. Guides the formulation of expected outcomes for quality
assurance requirements of third party payer.
5. Provides a basis for evaluation to determine if nursing care
was beneficial to the client and cost effective.

Parts of Nursing Diagnosis/The diagnostic statement
Each diagnostic statement has two or three parts

depending on the health care facility.
a two-part diagnostic statement consists of the
problem and Etiology.
The three-part statement consists of the following
components:

1.Problem Statement
The problem portion of a statement describes-
clearly and concisely a health problem a client is
having.
Use one of the NANDA approved nursing diagnostic
labels to state the problem
describes a physiological or psychological response
to a health problem. When writing use: altered,
disturbed, decreased, excessive, dysfunctionaletc

2. Etiology Statement
The etiology part of the diagnostic statement is the cause
of the problem.
Etiology may be physiologic, psychological, sociologic,
spiritual, or environmental.
describes contributing factors that influence development
of the response. Identifies the physiologic, psychological,
sociologic, spiritual, and environmental factors believed to
be related to the problem as either a cause or a
contributing factor.
Etiology identifies the factor that maintain the un healthy
patient state and prevent the desired change, thus directs
the nursing intervention. Unless the etiology is correctly
identified, nursing actions may be inefficient and
ineffective.

3.Sign and symptoms
You may need to include several signs and symptoms.
For instance, the client with pneumonia had cough with
thick sputum, abnormal breath sounds, increased
respiration, and difficulty breathing

Guidelines for Writing Nursing Diagnosis
1. Phrase the nursing diagnosis a patients problem or
alteration in health state rather than as a patient need
2. Use related to rather than caused by or due to
3. Write the diagnosis in legally advisable terms
4. Use non- judgemental language
5. Do not reverse the cause with the problem
6. Single nursing diagnosis should contain only one specific
problem
7. Avoid medical diagnosis

Guidelines for Writing Nursing Diagnosis Con
8. The problem and etiology should be expressed in terms of

that can be change
9. Check the diagnosis to make sure the problem statements
patient goals and that the etiology will direct the selection of
nursing measures
10. Defining characteristics should follow the etiology and be
lining by the phrase as evidenced by or as manifested by

3. Planning & Outcome Identification
Planning is the third step of the nursing process and includes
the formulation of guidelines that establish the proposed
course of nursing action in the resolution of nursing
diagnoses and the development of the clients plan of care.
It refers to the design of nursing strategies to resolve
patients problem
Once the nursing diagnoses have been developed and client
strengths have been identified, planning can begin. The
planning phase involves several tasks:
The list of nursing diagnoses is prioritized.
Priorities are classified as high (psychological or
Physiological).
Intermediate (non- emergency, non- life threatening) or
low (needs that may not be directly related to a specific
illness but may affect their future well- being).
Client-centered long- and short-term goals and out-comes
are identified and written.
Specific interventions
8/8/2017 are developed.
.
Planning & Outcome Identification Con
Purpose
Direct (Guide patient care activities )
keep continuity of care
Allow for the delegation of specific activities
The entire plan of care is recorded in the clients record.
.Once the list of nursing diagnoses has been developed
from the data, decisions must be made about priority.
Critical thinking enables the nurse to make decisions

about which diagnoses are the most important and
need attention first.
There are a number of frameworks used to prioritize
nursing diagnoses; however, those diagnoses involving
life-threatening situations are given the highest priority.
For example, the following nursing diagnoses would be
stated in this order
8/8/2017
of priority:
Planning & Outcome Identification Con..
1.Ineffective Airway Clearance related to excessive, thick
secretions and pain secondary to surgery and inability to cough
effectively
2.Risk for Injury (falls) related to un steady gait
3 .Imbalanced Nutrition: Less Than Body Requirements related
to nausea and vomiting

Planning & Outcome Identification Con..
Client-centered goals are established in
collaboration with the client whenever possible.
A goal is an aim, intent, or end.
Goals are broad statements that describe the
intended or desired change in the clients behavior.
If the client or significant others are unable to
participate in goal development, the nurse assumes
that responsibility until the client is able to
participate.
Client-centered goals assure that nursing care is
individualized and focused on the client.

Expected outcomes
An expected outcome is a measurable client behavior that
indicates whether the person has achieved the expected
benefit of nursing care.
It may also be called a goal or objective.
An expected outcome has the following characters tics:
Client oriented
Specific
Reasonable
Measurable
Expected outcomes are specific objectives related to the
goals and are used to evaluate the nursing interventions.
They must be measurable, have a time limit, and be realistic.
Once goals and expected outcomes have been established,
nursing interventions are planned that enable the client to
reach the goals.

Expected outcomes Con.
Examples of goals setting ,
Nursing diagnosis :-Knowledge deficit regarding to
postoperative care at home.
Goals: Client will state four postoperative risks before
discharge
Expected outcome -Client will identify need to
drink 2-3 liters of fluid every day
-Client will name three signs of infection
-Client will demonstrate aseptic wound care

Expected outcomes Con
Activities
Establish priorities based on nursing diagnosis
writing patient goal and out come criteria
Selecting appropriate nursing intervention
communicate the nursing care plan.

Con
Selecting Nursing Intervention
Nursing intervention is also called nursing orders
or nursing actions, are activities that will most
likely produce the desired outcomes (short-term
or long-term).
Examples:-
Offering fluids frequently
Positioning frequently
Teaching deep breathing exercise
Monitoring vital signs
Administering oxygen, etc. accordingly.
4.Implementation
actualization of the plan of care through nursing
interventions.
Implementation involves the execution of the
nursing plan of care derived during the planning
phase.
It consists of performing nursing activities that
have been planned to meet the goals set with the
client.
Nurses may delegate some of the nursing
interventions to other persons assigned to care for
the client.

Implementation Con
It is the action phase of the nursing process in
which nursing care is provided.
It is defined as the actual initiation of the plan
evaluation of the response to the plan and
recording of nursing action.
Activities include: Reassess, set priorities, perform
nursing interventions and record nursing action.

5.Evaluation
determination of the patients responses to the nursing
intervention and the extent to which the goals have been
achieved.
Evaluation, the fifth step in the nursing process, involves
determining whether the client goals have been met,
partially met, or not met.
It is the phase in which the nurse compares the patients
behavioral response with predetermined patient goals and
out come criteria.
If the goal has been met, the nurse must then decide
whether nursing activities will cease or continue in order for
status to be maintained.

Evaluation Con..
If the goal has been partially met or not been met,
the nurse must reassess the situation.
Data are collected to determine why the goal has
not been achieved and what modifications to the
plan of care are necessary.

Evaluation Con.
There are a number of possible reasons that goals
are not met or are only partially met, including:-
The initial assessment data were incomplete.
The goals and expected outcomes were not
realistic.
The time frame was too optimistic.
The goals and/or the nursing interventions planned
were not appropriate for the client.
Evaluation is an ongoing process.
Nurses continually evaluate data in order to make
informed decisions during other phases of the
nursing process.

Evaluation Con
Activities in Evaluation
Review patient goals and outcome criteria
Collect data (subjective and objective data) to judge
patients response to nursing intervention.
Measure goal attainment
Record the measure
Modify nursing care plan.

Documenting the Nursing Process
The ability to communicate clearly in writing is a
critical nursing skill.
Accurate, concise, timely, and relevant
documentation provides all the members of the
care giving team with a picture of the patient.

Con..
The nursing process is a systematic, rational method of
planning and providing nursing care. Its purpose is to
identify a client's health care status, and actual or potential
health problems, to establish plans to meet the identified
needs, and to deliver specific nursing interventions to
address those needs.
The nursing process is cyclical; that is, Its components follow
a logical sequence, but more than one component may be
involved at one time. At the end of the first cycle, care may
be terminated if goals are achieved, or the cycle may
continue with reassessment, or the plan of care may be
modified.

Summary of nursing process steps
1.A S S E S S I N G
Collect data
Organize data
Validate data
Document data
2.DIAGNOSING
Analyze data
Identify health problems ,risks, and strengths-
Formulate diagnostic statements

Con..
3. PLANNING
Prioritize problems/diagnoses
Formulate goals/desired outcomes
Select nursing interventions
Write nursing interventions
4. IMPLEMENTING
Reassess the client
Determine the nurse's need for assistance
Implement the nursing interventions
Supervise delegated care
Document nursing activities

Con
5. EVALUATING
Collect data related to outcomes
Compare data with outcomes
Relate nursing actions to client goals/outcomes
Draw conclusions about problem status
Continue, modify, or terminate the client's care plan

QUZI
Ato Agmassie comes DTGH , Emergency OPD at 5:30 AM
local time, Agmassie said, I have faced Diarrhea and cold
extremities before 03 days back and developed Vomiting
.
Ato Agmassie has also Difficulty of breathing ;Fever(38.9 oc)
According to the above case write Agmassies Nursing
Assessment; Diagnosis; planning;
Implementation;Evaluation?

Fun - Psy.dtu by Dejen G.

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Debr-Tabor University,

College of Health Sciences

Department of PSYCHIATRIC Nursing

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

CHAPTER:-ONE :-Naso Gastric Tube

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

Definition:- Passing a tube through a nasal cavity down the nasopharynx

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

To prevent stress on operated site by decompressing

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

The two most commonly used nasogastric tubes are:

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

Made of plastic or rubber openings near its tip.

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

Naso- enteric tubes are used for feeding.

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

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8/8/2017 Clamper or artery forcepsFUNDAMENTAL

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Preparing the patient _ explaining to the patient the purpose of the

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

A combination of three methods is recommended to check the tube has

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

Visual inspection is less helpful when the patient is receiving continuous

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

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Monitoring and managing potential complication patient with NG tube

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

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Objective:-On the completion of the lesson learners will be:

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

To remove inserted poison, other than corrosive substances like

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

when patients have a compromised, unprotected airway

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

The most dangerous risk is aspiration pneumonia, which is

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

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If you are using a tube with a bulb

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Definition: Aspiration is the withdrawal of fluid or gas from

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.

1. To relieve stomach or intestinal distension following

8/8/2017 FUNDAMENTAL OF NURSING BY DEJEN G.