Choking & Nasogastric Tube Procedures PDF

# Brainstem death ## Emergency Nursing Procedures ### Chocking #### Definition Chocking is the physiological response to sudden obstruction of airways. Foreign body airway obstruction (FBAO) causes asphyxia and is a terrifying condition, occurring very acutely with the patient often unable to expl...

# Brainstem death ## Emergency Nursing Procedures ### Chocking #### Definition Chocking is the physiological response to sudden obstruction of airways. Foreign body airway obstruction (FBAO) causes asphyxia and is a terrifying condition, occurring very acutely with the patient often unable to explain what is happening to them. #### Partial obstruction - effective Cough - non effective - Complete - effective - Consulas - unconssions #### Risk factors People at increased risk of FBAO include those with any of the following conditions or characteristics: 1. Altered level of consciousness 2. Neurological impairments with reduced swallowing and cough reflexes 3. Respiratory disease 4. Mental impairment 5. Poor dentition 6. Older age 7. Children in particular mobile babies and toddlers 8. Sedation 9. Eating risky foods (round sweets, nuts, grapes, and improperly chewed other food) #### Severity of airway obstruction - **Mild airway obstruction (effective cough):** patient able to talk and has an effective cough - **Severe airway obstruction (ineffective cough):** typically, patient responds "yes" by nodding their head without speaking, unable to cough effectively. ## Signs and symptoms of airway obstruction: 1. Universal sign of chocking 2. Coughing forcefully (mild or inability to cough (severe)) 3. Making high pitch sounds 4. Inability to breathe (gasping) 5. Pallor skin color 6. Panic or fear ## Procedure for Chocking ### Action | Rationale ------- | -------- Assess the presence of airway obstruction (Ask the patient "Are you chocking?") | To give the victim who is unable to speak the opportunity to respond by nodding. Assess the degree of airway obstruction. | To determine the most effective action that should be taken immediately. If mild airway obstruction: - Encourage the victim to lean forward - Encourage the victim to continue spontaneous coughing and breathing efforts - Stay with the victim - Monitor the victim condition | To increase intrathoracic pressure and force foreign object to get out. If mild airway obstruction persists, activate emergency medical system (EMS). | ### If severe airway obstruction and patient conscious (standing or sitting position): 1. Activate EMS 2. Perform up to five back blows: - Stand to the side and slightly behind the victim - Support the chest with one hand - Lean the victim forward - Give up to five back blows between the shoulder blades with the heel of the rescuer dominant had - Observe the victim for expulsion of the foreign body 3. Perform up to five abdominal thrusts: - Stand or kneel behind the victim - Wrap both arms around the upper part of the victim waist - Lean the victim forwards - Make a fist with one hand - Place the thumb side of fist against victims abdomen in midline between the umbilicus and the end of the sternum. - Grasp the fist with the other hand - Press the fist into the victims abdomen inwards and upwards. - Repeat up to five times and give each new thrust with a separate distinct movement 4. If the obstruction is still not relieved, continue alternating five back blows with five abdominal thrusts until the object is expelled from airway or the victim become unresponsive. ### N.B: For pregnant or obese victims use a chest thrust instead of abdominal thrust. ### If the victim is unconscious: 1. Support the victims to the ground. 2. Activate EMS 3. Open airway. 4. Remove an object if seen. 5. Start abdominal thrust 6. Open the victims mouth wide and look for object before each rescue breath 7. Remove the object using finger sweep if seen 8. Start CPR if the object not seen and patient arrested 9. Continue this procedure until the object dislodged or the victim starts breathing. ### Chest thrust in Pregnant #### Severity | Adult FBAO emergency assessment and management ------- | -------- Severe (ineffective cough) | Unconscious - Start CPR, Conscious - 5 back blows, 5 abdominal thrusts Mild (effective cough) | Encourage cough, continue to check for deterioration to ineffective cough, or until obstruction relieved. ## Nasogastric Tube Insertion "NGT" ### Definition: It is performed by insertion of a small or large bore tube through the nose and advanced through the esophagus into the stomach (nasogastric tube) or into the duodenum (nasoduodenal tube), or into the jejunum (nasojejunal tube). ### Purposes of nasogastric tube: #### Diagnostic purposes: 1. To obtain samples for gastric content analysis. 2. To evaluate upper gastrointestinal GI bleeding: presence and volume. 3. To administer of radiographic contrast to the GI tract. #### Therapeutic purposes: 1. To decompress gastric content after gastrointestinal surgery. 2. To administer of medications. 3. To administer feeding (gastric gavage). 4. To irrigate the stomach (gastric lavage) in the presence of: - Gastrointestinal hemorrhage - Ingested drugs or toxins ### Contraindications for NGT insertion: #### Absolute contraindications include the following: 1. Basal skull fracture 2. Recent nasal surgery 3. Confirmed esophageal stricture, tumor, or trauma #### Relative contraindications include the following: 1. Coagulation abnormality 2. Esophageal varices (Usually, a Sengstaken-Blakemore tube is introduced, but an NG tube can be used for lower-grade varices) or stricture. 3. Recent banding of esophageal varices. 4. Alkaline ingestion (the tube may be kept if the injury is not severe). ### Notes: - The naso gastric short-term use 30 days. - Are soft, flexible, small-bore Poly ure than or silience tubes Theatre 8 or 14 french-indiameter, 20 to to in che in Light. ## Gastrointestinal Emergencies ## Procedure for NGT insertion ### Action | Rationale ------- | -------- **1. Assessment** **a. Patients' chart** - Patients diagnosis & history of nasal surgeries or deviated septum - Physician order for type of tube, enteral lavage & purposes of insertion. - Obtain baseline coagulation studies & coagulant therapy. - Determine the need for analysis of gastric contents. **b. Patient** - Assess patient conscious level - Assess the need for insertion of gastric tube: - Inability to take food or medication by mouth. - History of ingestion of drugs or toxins. - Profound hypothermia. - Gastrointestinal bleeding - Identify history of nostril or oral or facial surgery or injuries, bleeding, varices, recent esophageal or gastric surgery. - Assess for signs of gastric distention or irritation (nausea, vomiting, abnormal bowel sound) | To identify contraindications To detect the risk of bleeding. To determine the ability of the patient to cooperate during the procedure. To identify the purposes of insertion and achieve the goal. To administer warm fluid to correct hypothermia. To reduce risk of injuries or bleeding. To avoid accumulation of secretions or air that may increase the risk of vomiting and aspiration. **c. Assessment continued** - Assess for gag reflex (using tongue depressor) - Assess nostrils for deviated septum. - Assess the patency of nostrils (occlude one and ask patient to breathe through nose, select one with better air flow) | To identify the risk of aspiration. To identify more patent nostril and choose tube size. To facilitate tube insertion. **II. Preparation** **a. Equipment** - NG tube (for adult patients) 16-18 French and place it into ice. - Glass of water with a straw - Water-soluble lubricant - Tommey syringe - Tape - Emesis basin or plastic bag. - Suction equipment - Towel or tissue paper - Tongue blade - Stethoscope - pH test paper - Flash light - Disposable gloves, goggles, gown. **b. Prepare environment** **c. Patient ** - Explain procedure. - Put the patient in high fowler position or semi-fowler with a pillow behind head and shoulders for unconscious patient or left lateral position with head down. - Ask the patient to blow his nose - Cover chest with towel.| To stiffen tube to prevent coiling during insertion. To gain patient cooperation. To facilitate passage of the tube into the stomach. To ensure patency of nostrils. To keep patient's gown clean. **III. Implementation** - Stand at the right hand if (right handed) - Estimate the length of insertion by (Fig (1)): - Measuring the distance from the tip of the nose to earlobe to xyphoid process down to just below the left costal margin - Triple the distance from the tip of the nose to earlobe - This point can be marked with a piece of tape on the tube. - Curve 10-15 cm of end of tube. - Lubricate 6-10 cm of distal end of nasogastric tube with water-based lubricant (Fig (2)). - Inser the tube to more patent nostril. - Direct the tube downward to thee pharynx when the tube hits the pharynx have the patient flex the head forward or flex the unconscious patient head. - Position the patient sitting upright with the neck partially flexed. - Ask the patient to hold the cup of water in his or her hand and put the straw in his or her mouth. - If, at any time, the patient experiences respiratory distress (cough, gag), is unable to speak, or has significant nasal hemorrhage, or if the tube meets significant resistance, stop advancing the tube and withdraw it completely. - Check back of pharynx with flash light and tongue blade if the patient continue to gag. - Continuous to pass the tube until marked position is at the rim of the nostril. - Rotate 180 if resistance exists. Tube may coil around itself. - Examine patient mouth using tongue blade. | To reduce transmission of infection. To ensure tube placement into the stomach. To take the anatomical shape of naso oropharangeal curve. To make the passage of tube easier and minimize mucosa trauma. To make the passage of tube easier. To facilitate the passage of tube into the esophagus. To advance tube into the stomach Tube may be advanced in respiratory tract To ensure that the tube placed into the stomach To ensure the tube isn't kinked. **IV. Post care** **a. Patient** - Put patient in comfort position. - Administer oral hygiene. | To promote patient comfort. To prevent infection & maintain integrity of oral mucosa. **b. Tube** - Reassess tube placement before installing any substances - Irrigate tube as a routine care to maintain potency. **c. Environment** - Rearrange environment & discard equipment **d. Self** - Remove gloves & wash hands. **V. Documentation** **a. Record** - Gastric tube size & types, - Time, place, the methods of placement verification - Patient tolerance **b. Report Unexpected outcomes** - Tube misplacement - Tracheal aspiration - Bleeding | To avoid aspiration. To reduce the transmission of microorganism. ## Measures to avoid occurrence of NGT related complication: ### Measures to reduce mucosal irritations: 1. Frequent oral and nasal care to remove any secretions. 2. Lubricate nostrils with water soluble lubricant to avoid crusting of secretions. ### Measures to maintain patency of the NGT: 1. NGT should be irrigated frequently with water. 2. Changing patient position to facilitate the drainage. 3. Frequent insuring of tube placement. ## Complications of NGT insertion: 1. Some degree of patient discomfort is common. Generous lubrication, the use of topical anesthetic, and a gentle technique may reduce the patient's level of discomfort. Throat irritation may be reduced with administration of anesthetic lozenges (e.g., benzocaine lozenges) prior to the procedure. 2. Epistaxis may be prevented by generously lubricating the tube tip and using a gentle technique. Other complications that may occur are respiratory tree intubation and esophageal perforation. 3. Pulmonary aspiration 4. Tube clogging & tube dislodgement 5. Mucosal trauma & bleeding 6. Misplacement 7. Sinusitis/otitis media 8. Distress/discomfort 9. Nasal septum erosion