Nasogastric and Nasointestinal Tube Removal
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Questions and Answers

A patient with a nasogastric tube is prescribed to have it removed. Which healthcare provider can the registered nurse (RN) delegate this task to?

  • A new graduate Registered Nurse (RN)
  • A practical nurse (PN) (correct)
  • A medical student
  • Assistive personnel (AP)

Prior to removing a nasogastric tube, why is it important for the nurse to review the client's medical record?

  • To assess the client's understanding of their medication regimen.
  • To confirm the client's preferred method of tube removal
  • To identify any allergies or conditions that may affect the removal process. (correct)
  • To determine the client's insurance coverage for the procedure.

Before initiating the removal of a nasogastric tube, which action should the nurse prioritize to ensure client safety?

  • Verifying the provider's order for tube removal. (correct)
  • Administering a pain medication to minimize discomfort.
  • Ensuring the client has signed a consent form for the removal.
  • Consulting with a dietitian regarding the client's nutritional needs.

What is the primary rationale for placing a client in high-Fowler's position before removing a nasogastric tube?

<p>Minimize the risk of aspiration. (B)</p> Signup and view all the answers

Why is it important to disconnect the nasogastric tube from suction or feeding prior to its removal?

<p>Prevent contents from draining into the client's lungs. (A)</p> Signup and view all the answers

What action should the nurse instruct the client to perform as the nasogastric tube is being removed?

<p>Hold their breath. (C)</p> Signup and view all the answers

If resistance is encountered while removing a nasogastric tube, what is the most appropriate nursing action?

<p>Stop the procedure and notify the provider. (B)</p> Signup and view all the answers

Following removal of a nasogastric tube, for what primary complication should the nurse assess the client?

<p>Aspiration (A)</p> Signup and view all the answers

A nurse is preparing to remove a nasogastric tube. What is the purpose of flushing the tube with water or air prior to removal?

<p>To clear the tube of contents to minimize aspiration risk. (C)</p> Signup and view all the answers

What information should the nurse include in the documentation after removing a nasogastric tube?

<p>The client's response to the procedure and skin condition. (A)</p> Signup and view all the answers

A nurse is preparing to remove a nasogastric tube from a client. Which assessment finding would necessitate delaying the removal and contacting the provider?

<p>The client has absent bowel sounds. (B)</p> Signup and view all the answers

When removing a nasogastric tube, why is it important for the nurse to clamp and kink the tube near the client's nose?

<p>To prevent aspiration of the tube contents and leakage. (B)</p> Signup and view all the answers

After removing a nasogastric tube, the nurse cleans adhesive residue from the client's face and provides oral hygiene. What is the primary rationale for these actions?

<p>To prevent skin breakdown and promote comfort. (A)</p> Signup and view all the answers

A nurse is teaching a practical nurse (PN) about removing a nasogastric tube. Which instruction is most important to emphasize regarding potential complications during the procedure?

<p>&quot;If any resistance is met, stop immediately and notify the provider.&quot; (D)</p> Signup and view all the answers

When reviewing a client's medical record prior to nasogastric tube removal, what specific information is most important for the nurse to identify to prevent complications?

<p>The client's allergies, especially latex or adhesive. (D)</p> Signup and view all the answers

A nurse is preparing to remove a nasogastric tube that was used for gastric decompression. What action should the nurse take regarding the gastric output in the collection container?

<p>Measure and record the amount of output in the collection container. (C)</p> Signup and view all the answers

What is the primary purpose of instructing a client to hold their breath during the removal of a nasogastric tube?

<p>To close the epiglottis and prevent aspiration. (A)</p> Signup and view all the answers

A client becomes cyanotic and begins coughing immediately after nasogastric tube removal. What is the nurse's immediate priority?

<p>Administer oxygen and assess respiratory status. (A)</p> Signup and view all the answers

A nurse is removing a nasogastric tube. Which action demonstrates proper technique to minimize trauma to the client?

<p>Using a smooth and steady motion to remove the tube. (C)</p> Signup and view all the answers

After removing a nasogastric tube, the nurse assesses the client's nares and skin around the nose. What is the nurse primarily assessing for?

<p>Loss of skin integrity and irritation. (D)</p> Signup and view all the answers

To ensure client safety, the nurse performs several actions before leaving the room after nasogastric tube removal. Which action is the MOST important?

<p>Ensuring the client knows how to call for assistance. (D)</p> Signup and view all the answers

A nurse is preparing to remove a nasogastric tube from a client following abdominal surgery. What specific assessment finding would require the nurse to collaborate with the provider before removing the tube?

<p>Surgical sutures near the nose that could be disrupted. (D)</p> Signup and view all the answers

Before removing a nasogastric tube, the nurse plans to flush the tube with 10 mL of water. Which outcome indicates that the flushing was successful?

<p>Water is easily instilled into the tube without resistance. (A)</p> Signup and view all the answers

A nurse is removing a nasogastric tube. Which action should the nurse perform immediately after removing the tube from the nares?

<p>Clean the nares and provide oral hygiene. (B)</p> Signup and view all the answers

A nurse is educating a client on what to expect during removal of a nasogastric tube. Which statement by the nurse is most appropriate?

<p>&quot;You might feel some throat discomfort as the tube is removed.&quot; (B)</p> Signup and view all the answers

A nurse is reviewing the steps for nasogastric tube removal with a newly hired practical nurse (PN). Which step, if performed by the PN, requires intervention by the supervising RN?

<p>The PN removes the tube with slow, forceful movements. (D)</p> Signup and view all the answers

A client reports a burning sensation and increased nasal congestion following removal of a nasogastric tube. Which intervention should the nurse implement first?

<p>Assess nasal passages and provide gentle saline rinses. (D)</p> Signup and view all the answers

Which action during nasogastric tube removal increases the risk of infection transmission?

<p>Using the same gloves to remove the tube and clean the client's face. (A)</p> Signup and view all the answers

What is the primary purpose of checking that the tip of the nasogastric tube is intact after removal?

<p>To ensure that a portion of the tube has not been retained in the client. (A)</p> Signup and view all the answers

The nurse is removing a nasogastric tube from an elderly client. Which modification to the standard procedure is most appropriate for this client?

<p>Loosen the tape gently and avoid pulling on fragile skin. (C)</p> Signup and view all the answers

After nasogastric tube removal, a client reports increased abdominal distention and nausea. Which action should the nurse take first?

<p>Assess bowel sounds and palpate the abdomen. (A)</p> Signup and view all the answers

A newly licensed nurse is observing an experienced nurse remove a nasogastric tube. Which statement made by the newly licensed nurse indicates a need for further teaching?

<p>&quot;It is important that I pull the NG tube out as quickly as possible.&quot; (B)</p> Signup and view all the answers

What nursing action is most important when ensuring client safety immediately after a nasogastric tube is removed?

<p>Ensuring the client’s call light is within reach. (B)</p> Signup and view all the answers

Which rationale supports the removal of gloves and application of a new pair after nasogastric tube removal but before cleaning the client’s face?

<p>To prevent cross-contamination after contact with the NG tube. (C)</p> Signup and view all the answers

Flashcards

NG or NI Tube Purpose

Inserted to decompress the stomach or administer nutrition/medications.

Delegation of NG/NI Removal

A nurse can remove NG/NI tubes if prescribed, but AP cannot.

Check for Allergies

To prevent allergic reactions during the procedure.

Verify Client Identification

To ensure the correct procedure is performed on the correct patient.

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Use Standard Precautions

To prevent transmission of infectious organisms.

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Use Disposable Pad

To collect any spillage of secretions during the procedure.

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Provide Tissues

To wipe the nose and mouth after tube removal.

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50-mL Syringe Use

Used to flush the tube or instill air prior to removal.

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Plastic Disposable Bag

Disposing of the tube and equipment per facility policy.

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Review Medical Record

To identify conditions that might affect the removal technique.

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Obtain Supplies

To ensure preparedness for the procedure.

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Provide Privacy

A part of maintaining client confidentiality.

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Introduce Yourself

Promotes a therapeutic nurse-client relationship.

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Hand Hygiene

An important infection control measure before client care.

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Two Unique Identifiers

To ensure correct procedure on the correct client.

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Confirm Allergy Status

To prevent allergic reactions during the procedure.

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Client Education

Reduce client anxiety and promote cooperation.

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Evaluate Indications to Delay

Assess for reasons to delay tube removal and consult provider.

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High Fowler's Position

Reduces risk of aspiration during the procedure.

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Place Disposable Pad

Prevents soiling of the client’s gown or bed linen.

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Offer Emesis Basin/Tissues

To reduce contact with body fluids and reduce transmission of microorganisms.

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Don Clean Gloves

To decrease contact with mucous membranes, blood, or body fluids.

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Disconnect Suction/Feedings

Prevents contents from draining into the client’s lungs upon removal.

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Detach Tube from Gown

Allows unobstructed removal of the NG or NI tube.

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Remove Nose Tape

Allows unobstructed removal of the NG or NI tube.

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Flush the Tube

Clears the tube and reduces the risk of aspiration during removal.

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Clamp the Tube

Prevents aspiration and leaking of tube contents.

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Deep Breath and Hold

Closes the epiglottis and prevents aspiration.

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Smoothly Pull the Tube

Avoids trauma to the client and reduces exposure to body fluids.

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Check Tube Tip Intact

Verifies no foreign object left in the client’s stomach.

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Measure Output (If Applicable)

Facilitates accurate documentation of client’s output.

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Dispose of Equipment

Prevents transmission of microorganisms.

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Clean Face/Nares

Excessive secretions may have accumulated; prevents contamination.

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Assess Skin Integrity

Detect and manage skin breakdown.

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Ensure Client Safety

Keeps falls from happening and prevents injuries.

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Study Notes

  • Nasogastric (NG) or nasointestinal (NI) tubes are inserted to decompress the stomach or administer nutrition/medications.
  • A registered nurse (RN) can delegate the removal of an NG or NI tube to a practical nurse (PN), but not to assistive personnel (AP).

Safety Considerations

  • Determine if the client has allergies to prevent allergic reactions.
  • Verify client identification to ensure the correct procedure is performed on the correct client.
  • Use standard and infection control precautions to prevent the transmission of infectious organisms.

Equipment

  • Nonsterile gloves and other personal protective equipment (PPE) are needed based on standard precautions.
  • A disposable pad or towel is used to collect any spillage of secretions.
  • Tissues are provided for the client to wipe their nose and mouth.
  • A 50-mL syringe is needed to flush the tube or instill air prior to removal.
  • A plastic disposable bag is required for disposal of the tube and suction equipment.

Step-by-Step Procedure

  • Step 1: Review the client’s medical record for allergies, medical history, medications, vital signs, lab values, and the provider’s order.
  • Step 2: Gather all necessary supplies.
  • Step 3: Provide privacy to maintain client confidentiality.
  • Step 4: Introduce yourself to the client to promote a therapeutic relationship.
  • Step 5: Perform hand hygiene and put on PPE if indicated.
  • Step 6: Identify the client using two unique identifiers.
  • Step 7: Confirm the client’s allergy status.
  • Step 8: Educate the client about the procedure to reduce anxiety.
  • Inform the client about potential throat discomfort.
  • Ask the client to hold their breath during removal.
  • Step 9: Evaluate the client for contraindications, such as inability to tolerate oral intake, absent bowel sounds/gag reflex, or surgical sutures near the nose/stomach.
  • Delay removal and consult the provider if contraindications are present.
  • Step 10: Place the client in high-Fowler’s position (30° to 45°) to reduce aspiration risk.
  • Step 11: Place a towel or disposable pad across the client’s chest to protect clothing and linens.
  • Step 12: Offer tissues and an emesis basin.
  • Step 13: Put on clean gloves.
  • Step 14: Disconnect the NG tube from wall suction or feeding infusion tubing, if present.
  • Step 15: Detach the NG or NI tube from the gown.
  • Step 16: Remove the tape or tube holder from the client’s nose.
  • Step 17: Flush the tube with 10 mL of water/saline or instill 30-50 mL of air to clear contents and reduce aspiration risk.
  • Step 18: Clamp the tube and kink it near the nose to prevent leakage.
  • Step 19: Instruct the client to take and hold a deep breath to close the epiglottis.
  • Step 20: Smoothly and steadily pull the tube out while collecting it in a towel or pad.
  • Stop immediately and notify the provider if resistance is met.
  • Step 21: Check that the tip of the tube is intact to ensure no part remains in the client.
  • Step 22: Measure and record the output in the collection container if the tube was used for decompression.
  • Step 23: Dispose of the NG/NI tube and equipment per facility policy.
  • Step 24: Remove dirty gloves and apply clean gloves.
  • Step 25: Clean adhesive residue, the nares, and provide oral hygiene.
  • Step 26: Assess skin integrity under the tube holder/tape and at the nares.
  • Step 27: Discuss findings with the client.
  • Step 28: Ensure client safety before leaving the room, with call light and needed items within reach.

Interventions for Unexpected Outcomes

  • Assess respiratory status for aspiration signs: cyanosis, coughing, or fever.
  • Stop immediately if resistance is felt during removal and notify the provider to avoid trauma.

Documentation

  • Document the date of removal, GI assessment findings, skin integrity, client response, and drainage measurement.

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Description

Learn about the safe removal of nasogastric (NG) and nasointestinal (NI) tubes, including necessary equipment, safety considerations, and the delegation of tasks to practical nurses. This covers allergies, client identification, infection control, and proper disposal of equipment.

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