Enteral Feeding

Enteral Feeding - From Excelsior College Flash Cards - 2005

1. Complies with established guidelines
2. For all feedings:
• selects the prescribed feeding
• positions the patient to promote feeding
• delivers the prescribed feeding
3. When assistance with feeding is designated:
• chooses an appropriate feeding device
• burps an infant under 6 months of age periodically as necessary
4. Administers the feeding at room temperature unless otherwise designated
5. When intermittent tube feeding is designated
• determines the amount of feeding to be administered
• calculates the drops per minute
• verifies the location of a nasogastric feeding, unless contraindicated by
• aspirating gastric contents and
• instilling 10-20 ml of air into the stomach while auscultating (5 ml for children under 2 years of age)
• measures gastric residual before initiating feeding
• reinstills gastric residual unless contraindicated
• initiates the prescribed feeding within +/- 30 minutes of scheduled time
• regulates the feeding rate to be delivered within the specified time when required by either
• adjusting the flow rate to within +/- 5 gtts/min of the calculated number of gtts or
• adjusting the flow rate of the enteral feeding pump to the exact number required to deliver the prescribed volume
6. When continuous tube feeding is designated:
• Within twenty minutes after beginning the Implementation Phase
• Verifies the accuracy of the flow rate by either
• counting the gtts/min currently flowing or
• documenting the flow rate setting on the enteral feeding pump on the PCS Recording Form
• Regulates the flow rate when required by either
• adjusting the flow to within +/- 5 gtts/min of the calculated number of gtts/min or
• adjusting the flow rate of the enteral feeding pump to the exact number required to deliver the prescribed volume
• Verifies the location of the nasogastric tube at least once during the PCS by the following methods, unless contraindicated by
• aspirating gastric contents AND
• instilling 10 - 20 ml of air into the stomach while auscultating (5 ml for children under 2 years of age)
• When measurement of gastric residual is designated
• measures gastric residual
• reinstills gastric residual unless contraindicated
• determines the amount of feeding to be administered
7. Records the kind of oral feeding administered
8. Records name and strength of the feeding product for a patient receiving a tube feeding
9. Records the amount of feeding administered

Mneumonic

RAT FEVER

Record
Amount of formula AND
Type of formula
Fowler's position to receive tube feeding
Examine gastric tube/abdomen
Verify placement - Verify G-Tube placement by aspirating gastric contents OR instilling 20 cc air bolus and listenting
Expiration date of formula
Record rate in 20 MINUTES!! - a pt theat has running tube feeding IS PART OF YOUR 20 MINUTE CHECKS!

Drainage and Specimen Collection

Drainage and Specimen Collection - from Excelsior College Flash Cards 2005

1. Complies with established guidelines
2. When drainage collection is assigned:
• assess the amount and color of drainage
• cleans the surounding skin or tissue when assigned
• inserts the tube into the appropriate body cavity
• when drainage is by tube:
• maintains or attaches tube to container
• maintains patency of the tube
• maintains drainage by gravity or suction apparatus
• removes the tube when assigned
3. When specimen collection is assigned
• obtains the designated speciment
• places the specimen in the designated container or on the designated surface
• ensure that specimen is labeled
• places speciment in designated area for transport
4. Records data related to drainage amount and color
5. Records data related to specimen collection
6. Documents and/or reports disposition of specimen

Selected Areas of Care - Wound Management

Wound Management

1. Complies with established guidelines
2. Assesses wound location, type, appearance, and presence or absence of drainage
3. When irrigation is designated:
• selects the designated solution
• determines the appropriate temperature of the solution (approximate)
• uses an appropriate irrigation delivery system
• positions a receptable for return flow
• irrigates without contaminating the wound
• protects the surrounding skin from contact with the drainage
4. Cleanses the wound with the designated solution
5. Applies the designated topical preparation
6. When wound protection is required
• removes the dressing without contaminating the wound
• removes the dressing without injuring the surrounding skin
• disposes of the soiled dressing in the designated container
• applies the dressing without contamination the wound
• secures the dressing
• labels the dressing with the date, time, and their initials
7. Records
• Data related to wound
• location
• type
• appearance
• presence or absence of drainage
• measures implemented to cleanse, irrigate, and protect the wound and surrounding skin
• patient response to measures implemented

Selected Areas of Care - Respiratory Management

Respiratory Management

1. Complies with established guidelines
2. Positions the patient to facilitate respiratory hygiene activity(ies)
3. Provides a receptacle to receive secretions as needed
4. Assesses the patient's respiratory status before initiating respiratory hygiene activity(ies) by:
• instructing the patient specifically to breathe in and out as deeply as possible moving the stethoscope from side to side
• observing breathing patterns
5. Directs the patient in or performs one or more respiratory hygiene activity(ies):
• Deep Breathing
• instructs the patient specifically to breathe in and out as deeply as possible
• repeats deepbreathing exercise as ordered or as indicated by the patient's condition
• Coughing:
• instructs the patient specifically to breath in and out deeply
• instructs the patient specifically to cough forcefully on third or fourth expiration
• provides for splinting, whiile the patient is coughing, if necessary
• Mechanical deviceds, such as those used for inspiratory spirometry, etc.
• instructs the patient specifically to use the device
• repeats respiratory exercise as ordered or as indicated by the patient's condition
• Chest Percussion
• claps the designated area(s) of the chest wall vigorously with cupped hands, unless contraindicated
• vibrates the designated area(s) of the chest wall vigorously, unless contraindicated
• Suctioning
• when suctioning by catheter is assigned
• verifies patency of the catheter
• sets the pressure on the suction machine as designated
• inserts the catheter before suctioning
• rotates the catheter continuously during suctioning
• suctions for no more than 15 seconds at a time
• repeats as necessary to remove secretions or
• when suctioning with a bulb syringe is assigned:
• deflates the bulb syringe prior to insertion
• inserts the bulb syringe into the patient's mouth and/or nares before suctioning
• aspirates secretions
• repeats as necessay to remove secretions
6. Reassesses respiratory status immediately after respiratory hygiene activities
7. Records
• bilateral breath sounds heard after treatment in comparison with those heard initially related to each of the above assessment findings
• abnormal breathing patterns
• respiratory hygiene activities implemented

Selected Areas of Care - Pain Management

Pain Management

1. Assess the patient's level of pain by:
• Asking an adult to rate level of pain using a 1-10 scale or visual analog scale or
• Asking a child 3 years of age or older to rate level of pain using a 0-5 faces scale or age-appropriate visular analog scale or
• Using the FLACC pain assessment tool to rate level of pain for a child ranging in age 2 months to 3 years of age or
• Observing behaviors indicative of pain in a patient unable to rate his/her pain (e.g. moaning, grimacing, cltching, restlessness)
2. Administers pain medication(s), when assigned
3. Reports the patient's level of pain to the assigned staff nurse
4. Provides one of the following relief measures:
• repositions the patient or assists the patientto a different position
• gives the patient a backrub
• uses relaxation an/or distraction techniques
• applies heat or cold when assigned
5. Reassesses level of pain by:
• asking an adult patient to rate level of pain using a 0-10 scale or visual analog scale or
• asking a child 3 years or older to rate level of pain using a 0-5 faces scale or age appropriate visual analog scale or
• using the FLACC pain assessment tool to rate level of pain for a child ranging in age 2 months to 3 years of age or
• observing behaviors indicative of pain in a patient unable to rate pain level (e.g. moaning, grimacing, clutching, restlessness)
6. Records
• patient's level of pain
• pain relief measures implemented
• patient response to measures implemented

Mneumonics

PRN

Pain scale 0-10
Reposition, relaxation (there are other things you can do to alleviate the patient's pain level, but this part of the "R" is a reminder for you to do something for the patient's pain)
Need to reassess

Fluid Management Mneumonic

"Hello - I use the mneumonic Won't I Be Glad I Prayed On This Day Saints Forever.

Wash hands in front of CE
Introduce and instruct pt of plan
Band check with MAR
Gel and glove up
IV site check
Pinch and palpate site
Off with the glove and GEL
Tubing check
Drip rate
Solution
Fluid level -state out loud to CE

**always GEL and document at the end of everything."

Carla Danz 3/6/10

IV PUSH

STATION 4: IV PUSH

MNEUMONIC: Clean Label Clean - FIGIWA - Flush Give Flush


6 ETOH PADS && 2 PAIR GLOVES


STEPS: *** MED -> MATH -> MAR ***


Right: Medication/Dose/Route/Time & Date/Exp Date/Allergies/Patient)


*** WASH THY HANDS BEFORE STARTING ***

Clean - Clean top of medication bottle.

Label - Label 3 empty syringes (2 NS & 1 Medication)

Clean - Clean NS port on bag

F - Draw up the two flushes && medication. (Med/Exp Date of flush bag)

I - Id the patient.

G - Glove up with non-sterile gloves

I - Inspect the IV site - "NO EDEMA"

W - Wipe IV port with alcohol

A - Aspirate - "I SEE A BLOOD RETURN" "** UNCLAMP TUBING **

Flush - Flush with NS

Give - Give medication over prescribed time (slow is better).

Flush - Flush

*** DO NOT TOUCH INSIDE STEM OF PLUNGER ***

*** CLAMP TUBING AND SIGN THE MAR ***

ERRORS:
1. Timing of push -- Easy to push much too fast.

2. Air bubbles -- Need to look carefully for air bubbles. Did not see bubble next to rubber part of plunger. Easy to get rid of bubble, but also easy to not see bubble.

3. Plunger stem -- ** THIS IS EASY TO FORGET **
-- Do not touch stem of plunger. Need to really watch this.

4. Backflow clamp -- Unclamp backflow clamp before attempting first flush.
-- Clamp backflow clamp after completing second flush.


OTHER: 1. Syringe package -- Open syringe packaging all the way. Just do it.

2. Syringe plunger -- Loosen up syringe before using.

3. Syringe type -- Watch 3cc vs 5cc syringes. You may be pushing more than three cc of medication. (per instructor)

4. Flush bag -- Verbalize "Zero point nine percent sodium chloride".

-- Verbalize "Expiration date"

-- Do not say "Normal saline" <-- This per instructor.

4. Pain relief -- You may sit down to do this station.

John Coxey (Syracuse, NY)