Surgical Procedures & Skills Flashcards
Describe indications for an NG tube placement
(1) ASPIRATION of GASTRIC CONTENTS
(2) ENTERAL FEEDING
for aspiration of gastric contents. This can either be diagnostic (for example, to determine if a gastrointestinal bleed is from an upper intestinal source) or therapeutic (as in intestinal obstruction)
enteral nutrition when swallowing is impaired, or the patient is unable to achieve adequate caloric intake orally.
Complications of an NG placement
(1) ASPIRATION
(2) PERFORATION - esophageal, gastric
(3) INTRAPULMONARY or INTRACRANIAL placement
aspiration (by inducing vomiting during placement, or misplacement in the trachea), esophageal or gastric perforation, intrapulmonary and intracranial placement. Patients with indwelling NG tubes are at risk of aspiration due to stenting open of the glottis and a depressed cough reflex.
Contraindications to NG tube
(1) FACIAL FRACTURES
(2) SEVERE COAGULOPATHY
(3) CLOSED HEAD INJURY
facial fractures (or suspicion of such) with cribiform plate injury who can suffer intracranial penetration with a blindly placed tube. A severe coagulopathy may be a relative contraindication for nasal passage of the NG tube. In both of these groups an orogastric tube (placed through the mouth instead of the nose) may be a safer alternative. Patients with esophageal stricture from alkali ingestion, especially recent ingestion, are at higher risk of esophageal perforation. Patients who are comatose may not be able to protect their airway and may vomit with tube placement and aspirate. Their airways should be secured (via endotracheal intubation) prior to NG placement. Placement of the tube can also cause gagging which can elevate intracranial pressure and may be dangerous in patients with closed head injury.
Overview of Steps to place NG tube
- Assemble the needed equipment.
- Explain the procedure to the patient.
- Appropriately position patient.
- Put on disposable gloves.
- Apply lubricant to tip of the tube.
- Place the tube into a nostril.
- Have the patient swallow as you advance the tube.
- Look for signs of inappropriate tube placement.
- Confirm intragastric location.
- Properly secure the tube.
- Properly document the procedure.
Equipment needed for NG tube insertion
- “chuck” to protect the patients clothing and bedding,
- a cup of water with a straw,
- a nasogastric tube (8-18, 16F is m/c)
- water soluble lubricant,
- tape, ph Tape
- a catheter tip syringe and a stethoscope.
- Suction tubing and collection container
Confirmation of placement of NG tube?
- aspirate 20-30 cc air, attach to NG and push, listen for gurgle
- Aspirate gastric contents, test pH <4 is 95%
- “high” KUB (you want to see the upper abdomen and lower chest) to ensure the tube is in the stomach. DO NOT USE A TUBE for feeding or administration of enteral medications until you are certain of an intragastric positioning.
If NG will be used for suction, which settings do you use?
INTERMITTENT suction, < 120 mm Hg.
If the tube is being used for aspiration of gastric contents, connect it to the suction tubing, and place it to intermittent suction (even when using a Salem sump tube.) The vacuum setting should be at less than 120 mmHg to prevent the suction from overcoming the venting capacity of the second lumen.
How do you remove the NG tube?
- disconnect it from the suction.
- Protect the patient’s clothing and bedding with a chuck,
- remove the tape from the patient’s nose, and
- quickly and gently pull the tube out.
Describe indications for placement of a Foley
catheter.
when continuous urinary drainage is required. This usually occurs when there is a need to closely monitor urine output or if the patient has a functional or mechanical obstruction.
●Urine output measurement in critically ill patients.
●During surgery to assess fluid status (ie, prolonged procedures, large volume fluid infusion).
●During and following specific surgeries of the genitourinary tract or adjacent structures (ie, urologic, gynecologic, colorectal surgery).
●Management of hematuria associated with clots.
●Management of immobilized patients (eg, stroke, pelvic fracture).
●Management of patients with neurogenic bladder.
●Management of open wounds located in the sacral or perineal regions in patients who are incontinent.
●Intravesical pharmacologic therapy (eg, bladder cancer).
●Improved patient comfort for end of life care.
●Management of patients with urinary incontinence following failure of conservative, behavioral, pharmacologic and surgical therapy
Can demonstrate Foley placement using proper sterile technique. Summarize.
- Assemble appropriate supplies.
- Properly position the patient
- Wash your hands.
- Don sterile gloves.
- Prepare kit/supplies
- Spread labia/grasp penile shaft with contaminated hand
- Prepare urethra with betadine swabs.
- Insert lubricated catheter.
- Note flow of urine through the catheter.
- Inflate balloon.
- Attach catheter to collection tubing.
- Secure tubing to patient’s leg.
First step for foley insertion.
the supplies are assembled for you in a sterile kit. The kit should include sterile gloves, sterile draping, the Foley catheter, betadine solution and sponges, disposable forceps, water soluble lubricant, a 10 cc saline filled syringe and tubing connected to a collection bag.
describe complications of Foley placement
perforation or creation of a false passage in the urethra, and urinary tract infection which can proceed to urosepsis.
larger catheter which may have a bit more stiffness. Alternatively you can use a Urojet which injects lubricant directly into the urethral opening and a Coude’ catheter (which is curved at the end) with the curvature pointing up. Again, do not force any catheter. If you have failed to catheterize the patient after these maneuvers, or if you suspect a false passage or perforation, consult a urologist.
Contraindications for foley?
ABSOLUTE - The only absolute contraindication to the placement of a urethral catheter is the presence of urethral injury which is typically associated with pelvic trauma. The presence of blood at the meatus or gross hematuria associated with trauma is evaluated first with retrograde urethrogram; urologic consultation and urethroscopy may be necessary.
RELATIVE - urethral stricture, recent urinary tract surgery (ie, urethra, bladder), and the presence of an artificial sphincter. For these issues, a urologist or urogynecologist should be consulted to assist with management
demonstrate Foley removal
Aspirate the saline from the balloon to deflate it. Gently slide the catheter out.
complications of IV placement
(1) PHLEBITIS - infection of vein
(2) THROMBOSED - thrombosis of vein
(3) THROMBOPHLEBITIS - thrombosis + infxn
(4) HEMATOMA - sucutaneous bleed
Cannulation of a vein allows a portal for bacteria to gain access to the vein, so infection or “phlebitis” is one complication that can occur. The vein can also become thrombosed, or can have both thrombosis and infection simultaneously (“thrombophlebitis”). Treatment usually involves removal of the catheter, elevation and heat application to the extremity and antibiotics in the case of infection. Rarely, in suppurative cases of thrombophlebitis, the vein must be excised. A hematoma (or a subcutaneous bleed) can occur if the vein is transgressed through and through (or “blown”). Application of pressure should stop the progression of a hematoma.
