BISIDIMO GENERAL HOSPITAL

NURSING SERVICE DEPARTEMENT

NURSING PROCEDURES AND INTERVENTIONS
PROTOCOL

Nov. 2015 E.C

 1. BANDAGING
Bandaging is an important part of nursing care and treatment in every healthcare facility.
Properly applied bandaging must meet its purpose and fulfil the aesthetic criteria. It must be
applied so that it does not restrict, but is not too loose. If administered to an open wound, both
the dressing and the bandage must be sterile in order to prevent infection.
Bandaging material according to use
1. Protection – protects the wound from the cold, impurities, secondary infection, e.g. gauze
square, gauze bandage, plaster, etc.
2. Compression – pressure bandage used for bleeding – compression of vascular injuries; also
included in this category are elastic bandages, compression stockings, leg bandages – gauze
bandage, triangular bandage – First Aid
3. Fixation – fixing materials are applied to strengthen the bones and joints, i.e. a broken bone;
included are adhesive plasters, starch bandage, plaster bandage etc. 4. Supporting – maintains a
particular part of the body in the desired position, i.e. injury, paralysis, e.g. starch, Zink paste
bandages, splints.
5. Extended wear – a stretching aid; attached to compensate for the shortening of the limb
caused by a broken bone or by damage to a joint by pulling or countermovement (splints, plaster
bandages, specific aids, devices with pulleys and weights).
6. Redressing – corrective aid; attached to the affected part of the body to facilitate a gradual
change in the shape or growth in another direction, used mainly in pediatric orthopedics.
Bandaging material
The most common dressing material is a fabric such as cotton, flax but also synthetic and elastic
fabric materials. Some materials are solid; others are adhesive, or can copy the physiological
shape of the human body.

Triangular bandage
This is the simplest dressing aid, most often used in first aid. It is made of cotton fabric – a calico
bandage or a bandage from nonwoven fabric for single use. Hydrophilic gauze
Fabric with a high content of natural fibres (approximately 70% cotton and 30% viscose), i.e.
ensures high absorbency. The fabric is used in the manufacturing of bandages, gauze squares,
tampons, gauze drains.
Bandage rolls
They are rolled strips of fabric, produced in widths of 3 – 30 cm.
Hydrophilic bandage – hydrophilic gauze is used to cover wounds; the sterile forms are used as
individual wound dressings. The bandages are light and permeable. Flexible elastic bandages
can be divided into cohesive bandages, bandages with a medium compressive effect and
bandages with a strong compressive effect. Cohesive bandages contain a high percentage of
natural fibre, and are impregnated with latex, which provides good cohesion. It is used to dress
the joints and conical body parts. Bandages with a medium compressive effect and bandages
with a strong compressive effect are used to attach a supporting dressing to injuries, where there
is damage to the musculoskeletal system, to attach a pressure bandage for bleeding and also in
sports bandaging.
Fixing bandages are hydrophilic bandages impregnated with a firming agent to reinforce the
bandage.
Zink paste bandages are impregnated with a special paste. When attaching these bandages, it is
necessary to take into account that they contract during drying, therefore they should be attached
loosely. Their surface is sticky, so the bandaging must additionally be covered with a hydrophilic
bandage.
Starch bandages are made of stiff hydrophilic gauze, impregnated with wheat, potato or rice
starch. They are wrapped in strips of paper, and stored in a dry place until application. They are
used to strengthen the joints in minor injuries. Before use, the bandage must be thoroughly
soaked in hot water until the water penetrates all the layers, then wrung dry before application.
The starch bandage is applied over a cotton wool dressing attached with a hydrophilic bandage.
Plaster bandages are impregnated with plaster. They provide reliable fixation of the broken
bone. It is a hydrophilic bandage which is impregnated with fine plaster. The bandages are
wrapped in moisture-proof packaging; moisture would harden the plaster and the bandage would
be spoiled. Before use, the bandage is soaked in a 40°C hot water; the bandage is not moved at
this point so as not to spill the plaster. Then it is removed and gently wrung and then
immediately attached. Attaching requires experience as it must be done quickly – the time for
molding the bandage is short (2 - 3 minutes).
Elastic sleeves and elastic mesh bandages Elastic sleeves (e.g. Stulpa, Raucotube) – suitable
for fixation – attached to cover the wound, also suitable as a dressing and as a sleeve for starch,
zinc paste bandages and plaster bandages. Elastic mesh bandage – (e.g. Pruban, Raukoflex) –
used for fixation and protection for various types and sizes of wounds. The bandages are
flexible, do not slip or stretch. They are made in sizes six to nine. They come in sizes suitable to
attaching to a finger to sizes suitable for bandaging the chest.
Compressions Gauze
Compression bandages (e.g. Sterilux ES) – is made of hydrofile gauze, are absorbent, soft and
permeable. The disadvantage of protecting the wound with a gauze compression bandage is that
it sticks to the wound, which hurts. They are made in different sizes.
Multi-layer absorbent compression bandages (e.g. Basepon, Santin, Steripore, Cosmopor) –
have an especially adapted contact layer that ensures painless removal and allows drainage of
secretions into the absorbent core. The reverse side does not leak the secretion, i.e. it prevents
secondary contamination.
Special compression bandages For example: Sorbalgon – nonwoven compress made of calcium
alginate fibres. Tender Wet dressing with absorbing polyacrylate element (activated with
Ringer's solution). It is used to treat infected wounds, and is difficult to access in deeper layers.
Hydrocolloid compressions (Hydrocoll, Hydrosorb) – self-adhesive with gel pad core. They
are made in different shapes and sizes. These are used to protect large wounds, accelerate the
process of granulation and epithelization. They are suitable for the treatment of chronic wounds;
see the chapter on wound dressing. They can easily be removed. The advantage of their
transparent foil is that the wound can be checked without having to change the dressing. The
compression is replaced as needed, according to the wound secretion.

Cotton wool
Cotton wool is a fibre. It is made of cotton or cellulose. Types of cotton wool products: Medical
cotton wool is made of cotton fibres. It is used in the manufacturing of cotton buds, or it is a part
of other absorbent materials such as gauze squares and hygiene products for incontinent patients.
It is also used as base material under plaster and splints.
Cellulose wadding
It is made from cellulose. It is used in many nursing interventions. It is absorbent paper in rolls
or in various sized squares, depending on the use. It is also made in the form of perforated strips,
which are later separated into individual squares.
Plasters
Plasters are used to reinforce bandages. They are made of woven and nonwoven fabric, which is
coated with rubber resin or with non-irritating polyacrylate adhesive. They are applied to dry and
clean skin. Their most common use is in the fixation of bandages, probes, peripheral cannulas,
etc.
Traditional plasters are made in skin coloured strips with an adhesive layer of rubber resin.
They are very sticky, difficult and painful to remove from the skin. They are made in widths
from 1.5 – 30 cm, and can be perforated.
Artificial silk plasters – solid fixation patches made of artificial silk with strong adhesion. They
are used in patients with sensitive skin and are porous and water vapour permeable, so that the
skin can breathe. They can be used to attach probes, cannulas and catheters and for fixation of all
types of dressings. They can be easily removed and do not leave unwanted adhesive residues on
the skin.
Plasters made of porous and transparent foil are hypoallergenic, porous and transparent,
suitable for fixation of all types of dressings, for transparent fixation of cannulas, probes,
catheters etc. They are also suitable for patients with sensitive skin.
Plasters from soft nonwoven material are porous and water vapour permeable, the skin can
breathe and does not sweat. They are ideal for patients with particularly sensitive skin. They do
not cause maceration even with long-term and large area fixation of dressings. The wound can
be protected against external moisture, with Omnipor – hydrophobic impregnation. The plaster
can be used both crosswise and lengthwise.
Bandaging technique
General principles for bandaging
• Explain to the patient the reason and the method of bandaging.
• Ensure patient comfort – toilet visit, comfortable position, i.e. sitting down or lying on the bed.
• Respect the patient’s physiological abilities.
• Ask the patient to participate.
• Ensure the patient’s dignity.
• If possible, always face the patient during the course of bandaging.
• Maintain constant contact with the patient, monitor their condition.
• Prepare the aids within reach, near the patient.
• Put the part of the body that will be bandaged into a position that is the closest to the
physiological position and ensure that this position will not change during bandaging.
• Sometimes it is necessary to remove body hair or cut the hair on the head; the skin must be
clean and dry before bandaging.
• Apply rolled up gauze or cotton wool to prevent intertrigo in areas where two layers of skin
touch (armpits under women’s breasts, etc.).
• Before bandaging, the wound is first protected with sterile material.
• Select the appropriate type of bandaging in terms of size.
• During bandaging, the bandage roll is firmly held in the dominant hand while it is unrolled into
the palm.
• The bandage is first secured with a spiral turn (the end of the bandage is folded under the
second turn).
• The bandaging always starts at the narrowest point and proceeds to the widest point upwards,
towards the heart (except for hand and toe bandaging), the next turn overlaps the previous turn
by about two thirds.
• The turns are always in the same direction.
• The bandaging finishes with a spiral turn and a lock or it is secured with plaster tape (always
outside the wound).
• The turns should not be too tight or too loose, the completed bandage is effective and neat

Catheterization
Bladder catheterization involves inserting a sterile catheter through the urethra into the bladder.
Bladder catheterization is performed only as the last resort, because it poses a risk of infection in
the urinary tract. A urinary catheter is usually inserted:
• In patients with urinary retention,
• To determine the volume of residual urine (residual urine remaining in the bladder after
urination) and to empty the residual urine,
• In some cases, in patients with urinary incontinence,
• In sterile urine sampling for laboratory testing for patients who cannot provide a urine sample
themselves,
• In order to rinse the bladder and administer drugs into the bladder,
• For continuous monitoring of urine output (in unconscious patients, after complicated and long
surgery, after severe injuries to the lower limbs and pelvis, in patients with paralysis of the lower
limbs, with burns). Types of bladder catheterization:
• Short-term – for emptying the contents of the bladder; the catheter is removed after the
procedure,
• Long-term – the urinary catheter is inserted over a long period of time; the catheter is fixed in
the bladder with a balloon filled with sterile saline.
Commonly used short-term urinary catheters:
• Nelaton catheter – a straight catheter with a round tip; used in women, men and children,
• Tiemann catheter – a straight catheter with a curved tip; used in men
Commonly used long-term urinary catheters:
• Folley catheter – made of flexible latex or silicone with a balloon installed; the mouth of the
catheter is adapted for connecting to a collection system.
All types of urinary catheters are made in different sizes, both in the circumference and diameter.
Catheter diameter sizes are measured in Charriere (CH) also know as French gauge (Fr). No.1 =
1 CH = 1 Fr = 1 mm circumference and 0.3 mm diameter (No. 18 = 18 CH = 18 Fr = 18 mm
circumference and 5.4mm diameter). Each catheter package is marked with a number.
The package for long-term catheters also indicates the recommended volume of fluid for filling
the fixation balloon. Catheters are sterile packed and usually made of silicone (allowing for a
long-term catheterization - 21 days), latex or PTFE-coated. Catheterization should be
administered strictly aseptically.
Preparation of aids
• Sterile urinary catheter (short-term or long-term)
• Sterile gloves
• Sterile squares and swabs
• Mucous membrane disinfectant
• Anesthetic gel
• Kidney bowl
• Wadding cut into squares
• For long-term catheter – a syringe with a sterile solution to fill the fixation balloon, tweezers
(not always) and a drainage kit with collection bag
Short-term catheterization in females
The catheterization is administered by a general nurse or a midwife who is responsible for gentle
and sterile insertion.
Patient preparation The preparation is both psychological and somatic. Psychological
preparation – the reason and the course of catheterization are clearly explained to the patient. She
is assured that the procedure, under normal circumstances, does not hurt. The nurse shows
understanding for the concerns and discomfort feelings of the patient and patiently answers all
the questions.
The nurse must ensure maximum privacy during the procedure. The catheterization is
administered either in the designated room or in the room on the patient’s bed. The nurse’s
attitude and demean our strives to earn the patient's trust and willingness to cooperate. Somatic
preparation – a thorough genital hygiene is inevitable; the cleansing is administered using a
suitable mucosa disinfectant.
The somatic preparation in a bedridden patient is administered by the nurse. Position – the
female patient is put in to the supine position with her legs flexed and spaced apart.
Preparation of aids
• Sterile urinary catheter (short-term Nelaton catheter)
• Sterile gloves
• Sterile squares and swabs
• Anesthetic gel (as customary on the ward)
• 2 kidney bowls (bedpan)
• Wadding cut into squares
• Mucous membrane disinfectant
• Sterile test tube for a urine sample

Working procedure
• Verification of doctor hours;
• The patient is provided in privacy;
• The nurse explains the procedure; the female patient washes her genitals prior to the procedure;
the bedridden patient receives nursing care in regards to genital hygiene;
• The nurse undergoes hand hygiene and disinfection prior to the procedure;

• The sterile aids are prepared next to bed so the nurse can use them while wearing sterile gloves;
• The female patient is placed in the supine position with flexed legs;
• A kidney bowl (or bedpan) is placed near the genitals in order to take a urine sample, a second
kidney bowl is for the swabs;
• The swabs are moistened with disinfectant, sterile gloves are put on;
• Using the non-dominant hand (thumb and index finger), the nurse separates the labia majora;
disinfects the labia major, one swab – one wipe anterior to posterior; proceeds from the pubic
area to the anus; the third swab used to disinfect the centre, across the urethral meatus;
• The hand that separates the labia major has now become non-sterile, therefore it must remain in
the same position and reveal the urethral meatus throughout the insertion of the catheter;
• The catheter is carefully removed from the packaging and held about 5 cm from the tip,
between thumb and index finger; the end is held over the kidney bowel into which the urine will
be drained;
• Anesthetic gel is applied to the tip of the catheter (this can be done in advance, depending on
ward practice);
• The patient is asked to relax the muscles and to take a deep breath;
• The catheter is gently inserted in the meatus and advanced along the urethra approx. 5 - 10 cm
deep;
• If a urine sample is required for microbiological examination, it is collected during the urine
outflow into the prepared and labelled test tube;
• After the procedure is completed, the catheter is gently removed and discarded in the kidney
bowl; the genitals are wiped with a pulp square;
• The patient is put back in the original and comfortable position;
• The patient receives information about the next steps with respect to their health condition,
from a doctor;
• Used disposable aids are discarded with other infectious waste, kidney bowls are put into
disinfectant;
• Depending on the doctor’s prescription, the urine sample is assessed or is sent to the laboratory;
• Hand hygiene and disinfection;
• The procedure is recorded in the documentation;
• Any changes are reported to the doctor.

Catheterization in male patients

Catheterization in men is usually administered by a male doctor with the assistance of a nurse.
The catheterization procedure in men can be conducted under applicable law by a specialized
nurse, qualified in intensive care. The catheterization procedure in men differs from female
catheterization in several aspects.
Preparation of aids
• Sterile Tiemann catheter (size as per doctor’s instructions; the nurse prepares a selection of
sizes)
• Sterile tweezers
• Sterile gloves
• Sterile squares
• Sterile swabs for disinfection
• Mucous membrane disinfectant
• Local anesthetic (e.g. Instillagel, Aqua Touch Jelly)
• 2 kidney bowls
• Eventual sterile test tube for urine sampling

Working procedure
• Verification of doctor instructions
• Washing and disinfection of hands
• Explanation of the procedure to the patient and provision of privacy
• Genital hygiene prior to the procedure
• Sterile aids are placed nearby so they can be handled with sterile gloves
• The patient is placed in the supine position with flexed legs
• Two kidney bowels are designated for urine sampling and used swabs
• The doctor and nurse put on sterile gloves; swabs are moistened with disinfectant
• The doctor firmly holds the penis below the glans,
• The second hand disinfects the glans penis using swabs and disinfectant solution, from the
urethral meatus to the edge, using a new swab for each smear
• The doctor lifts the penis vertically to the body and pulls it slightly upwards; applies an
anesthetic gel to the urethra
• The catheter is slowly inserted, about 15 cm deep until urine begins to flow
• The nurse presses the mouth of the catheter upwards and after inserting the catheter into the
bladder, it is positioned over the kidney bowl into which the leaking urine is captured
• After the procedure is completed, the doctor gently removes the catheter and wipes the outer
areas of the urethra with pulp.
Working procedure using instruments
• The nurse prepares the necessary aids and familiarizes the patient with the procedure
• Genital hygiene prior to the procedure
• The patient lies on the bed or on the examination bed in a supine position
• The doctor and the nurse carry out hand hygiene and disinfection; the doctor puts on gloves
• The nurse passes the tweezers to the doctor and prepares the swabs for disinfection of the
external urethral meatus
• The nurse also prepares a sterile catheter and local anesthetic
• The catheter must remain sterile!
• The nurse passes the catheter to the doctor who inserts it, using tweezers, into the urethra
(approx 12 – 15 cm deep)
• The nurse catches the flowing urine into the kidney bowl or into a sterile and labelled test tube;
measures the volume and records it
• The nurse cleans and disinfects the aids according to the applicable standards of the ward
• In the event of urine sampling, the nurse sends the test tube with the sample into the laboratory
with the fully completed request form.
Urethral catheterization in children
The procedure is administered relatively less often, e.g. for urine bacteriological testing.
Catheterization in children is special in terms of preparation before procedure, securing the child
(infant, toddler) and in the selection of a suitable catheter. The procedure is performed by a
doctor for young children; in older girls by a female doctor or a nurse. The procedure is identical
to the above procedures for female and male catheterization.
Complications during catheterization
• Perforation of the lower urinary tract – rupture of the lower urinary tract in forced insertion
of a urinary catheter
• Urinary tract infection – introduction of infection into the lower urinary tract
• Paraphimosis - occurs when the foreskin is pulled back behind the penis glans and stays there;
it is necessary to pull the foreskin back over the glans penis after short-term or longterm
catheterization
• Urethral sphincter injury – a catheter is inserted very gently and considerately; the patient is
asked to cooperate; the patient lies calmly, takes slow and deep breaths and concentrates fully on
breathing which induces a calm state of mind, releasing tension in the sphincter.
Patient care after the procedure
The patient is reminded of the need for increased genital hygiene (washing with soap and water).
A long-term catheter is replaced every 3 weeks or as needed. Silicone catheters can be inserted
for even longer (2 – 3 months), depending on the manufacturer’s recommendations and the
budget of the ward. The collection bag without the discharge valve is replaced as needed (1 – 2x
a day), the discharge collection bag even later, depending on the ward and the manufacturer's
recommendations.
If the collection bag includes an anti-reflux valve, it can be used for 7 days or according to the
manufacturer’s recommendation. It is important to use disposable gloves when handling a
catheter and collection bag. Mobile patients must be instructed not to bend, twist or pull the
connecting tube from the catheter.
Care of aids after use
The nurse carefully washes, disinfects and cleans all the aids which will be reused, instruments
(e.g. tweezers) are prepared for further sterilization. Disposable aids are discarded as infectious
waste as is customary on the ward.

Insertion of IV cannula
Purpose
• Administration of drugs via the parenteral route (antibiotics, cytostatics).
• Administration of infusion or transfusion solutions.
• Fast supply of fluid into the bloodstream.
• Long-term parenteral nutrition.
When choosing an appropriate site for vein puncture, it is necessary to take into account the
clinical condition of the patient, the age, the condition of the peripheral venous system, the size
of the cannula, the planned therapeutic approach, how long the cannula will remain inserted, the
type of drug administered, and if the blood will be repeatedly taken for examination.
A peripheral venous puncture is usually administered to adults on the back of the hand, on the
forearm and around the cubital fossa. The venous system of the lower limbs is only used when
necessary and in exceptional cases.
The intravenous cannula is selected according to:
• Knowledge of the anticipated therapeutic procedure (cannula length, type of therapeutic
solution, volume of solution administered, administration rate);
• Knowledge of the condition of the peripheral venous system.
General use of intravenous cannulas
• For quick blood transfusion - size 14 – 16G.
• For fast transfusion of large volumes of fluids and fluids with high viscosity - size 17G.
• In treatment with large volumes of blood or fluid - size 18G.
• In long-term medication – size 20G.
• For cancer patients, in long-term medication, or in patients with thin veins - size 22G.
• For pediatric patients, newborns, patients with fragile veins – size 24 – 26G.
• The cannula must never fully obstruct the inner lumen of the vein!
Patient preparation
• Check the patient’s identity (see Fig. 13.5-4).
• Assess the patient’s clinical condition.
• Explain the procedure to the patient.
• Put the patient in the appropriate position (lying down or half-sitting).
• Adjust part of the patient's clothing so it does not obstruct access to the site of the peripheral
venous catheter.
• Ensure a suitable position of the limb for inserting an intravenous cannula.
• Select the appropriate injection site.
Aids preparation
IV cannula of appropriate size, 10 ml syringe, saline, aspiration spike, disinfectant, rubber
gloves, Esmarch tourniquet, gauze squares (swabs), sterile dressing for cannula fixation, kidney
bowl, container for storing used needles, disposable pad to prevent soiling of bed and clothing,
extension (connection) tubing and infusion solution as prescribed by a doctor
Performing the procedure
• Check the integrity of the intravenous cannula packaging, and the expiration date.
• Wash and disinfect your hands.
• Maintain verbal contact with the patient throughout the procedure.
• Fill the connecting tubing with saline and rinse it.
• Apply a tourniquet (Esmarch tourniquet) about 15 – 20 cm above the venipuncture site. Tie the
tourniquet to prevent the blood flow in the veins, but not so as to interrupt the blood flow in the
arteries. Check if the radial pulse is still palpable which indicates that the blood flow through the
arteries has not been interrupted.
• Place the limb in the appropriate position (below the patient's heart); gravity slows the venous
return and expands the vein; dilated blood vessels can be punctured more easily.
• Palpate the injection site.
• Select a suitable site for cannulation. Inadequately filled veins can be enhanced by additional
measures e.g. clenching the fist, lowering the position of the limb, external heat application, etc
• Put on disposable rubber gloves which do not need to be sterile.
• Disinfect the injection site. In order to achieve the disinfecting effect, allow the disinfectant to
dry (about 1 min.), apply disinfectant gently, the disinfected area must be large enough; the
disinfectant is applied in one direction or in circular movements from the middle of the
anticipated injection site.
• It must not be touched after it has been disinfected!
• Remove the cannula from the original packaging, remove the protective cap.
• Hold the cannula with a three-point grip (between the index and middle finger of the dominant
hand; the thumb fixes the bottom part of the cannula).
• Anchor the vein by pulling the skin with the thumb of your non-dominant hand; this will also
reduce the pain during penetration of the needle into the tissue.
• The needle is inserted at a 30° angle upwards; after the needle pierces the skin, tilt the needle so
that it is nearly parallel to the skin, and insert it in the direction of the vein 1-2 cm deep;
decreasing the angle reduces the likelihood of piercing both walls of the vein.
• The entry of the needle into the vain is indicated by the presence of blood in the cannula
flashback chamber.
• After the puncture, quickly remove the tourniquet from the limb.
• Do not insert the needle any further but ensure the plastic part of the cannula is also in the vein.
• After successful inserting the cannula into the bloodstream, place a finger over the vein above
the tip of the cannula to prevent bleeding when removing the needle stylet
Procedure
• Put on the gloves
• Loosen the tape strips that hold the connecting tube.
• Using the dominant hand, release the sterile dressing from all sides, pulling towards the
patient’s skin while holding the inserted cannula with the non-dominant hand.
• Put the IV cannula dressing into the kidney bowl.
• Use a sterile swab with disinfectant to press on the inserted cannula while removing the
catheter.
• Put a plaster on the injection site.
• Check that the peripheral venous catheter is not broken; otherwise immediately report back to
the doctor due to the risk of embolism.
• Record the cannula removal into the patient’s documentation.
Complications of the procedure
• Hematoma – as a result of failed insertion of the cannula and a puncture or when removing the
cannula. The prevention of this is a carefully planned and executed procedure. The formation of
the hematoma can be prevented by pressing the point of puncture for 3 – 4 minutes after removal
of the cannula, elevating the limb and for patients with anticoagulant treatment by attaching a
pressure bandage for at least 15 minutes.
• Extravasation - leakage of administered substances into the tissue outside the vascular bed.
The leakage of certain substances can cause tissue necrosis. In this case the patient typically
complains of a burning sensation, pain, and hardening of the injection site. During prolonged
leakage into the subcutaneous tissue, the limb begins to swell. If extravasation is suspected,
discontinue the infusion, inform a doctor, remove the cannula, elevate the limb, monitor the
extravasation site and record all changes and the course of healing in the nursing documentation.
• Phlebitis – inflammation of the superficial vein manifested by tenderness, pain, redness,
swelling, strips, palpable hardening in the vein and suppuration. If a blood clot is formed in a
vein independently from the presence of inflammation of the vein it is referred to as
phlebotrhombosis.
• Embolism – this can occur in all forms of IV therapy; air embolism occurs if there is negative
pressure in the vein, for example, if the injection site is above the level of the heart, or due to
insufficient venting of the infusion set; embolism is caused by a blood clot in the cannula due to
flushing a blocked cannula and when cutting off the end of the cannula tip of the cannula when
re inserting the needle into the plastic part of the cannula.
• Allergy to a disinfectant or an administered drug.
• Injected artery or nerve during an inappropriate choice of injection site for an intravenous
cannula.
Gastric tube insertion/ NG Tube Insertion \
Gastric juice is a liquid secreted by the glands in the lining of the stomach (1 – 3 litres daily),
containing free or bound hydrochloric acid which most significantly contributes to the acidity of
the gastric juice. Hydrochloric acid (HCL) activates pepsinogen into the enzyme pepsin; the
tissue increases in volume between the muscle bundles, therefore supporting digestion, converts
the trivalent iron to divalent, changes the calcium carbonates to calcium chlorides making them
readily absorbable, and the acidic reaction destroys the germs and protects vitamins C, B1 and
B2.
Methods of gastric juice collection
The direct (invasive) method is used to examine the gastric chemistry – a collection of gastric
juice via an inserted gastric tube, or by an indirect method of estimation i.e. examination of urine
with the Acid test. The indirect method was used especially in the past and is rarely seen in the
present day.
It is used in children, as it is less intense for the patient. Examination of gastric chemistry has
only a limited diagnostic value compared to the currently preferred endoscopic diagnostic
method.
A gastric tube is inserted:
• If the patient is unable to receive sufficient food and fluid volumes orally;
• As prevention of nausea, vomiting and stomach distension in certain diseases in the digestive
tract and after some surgical procedures; with continuous drainage of gastric juices;
• For sampling stomach contents for laboratory examination;
• In gastric lavage in poisoning or drug overdose.
The gastric tubes are made from flexible latex, polyurethane or silicone material, in various
circumference sizes, diameter and length. Numbering is in Fr., i.e. the same as in urinary
catheters (see short-term bladder catheterization). The tubes are in sterile packaging, labelled
with the exact size and type.
The most frequently used gastric tubes are:
• Levin tube – flexible, made of plastic or rubber, with a single lumen and small inputs at the
end of the tube.
• Salem sump tube – has a double lumen, the larger lumen allows for easy suction of gastric
contents and the smaller lumen allows for air to be drawn into the tube which equalizes the
vacuum pressure in the stomach; this prevents the suction eyelets from adhering to the stomach
lining.
Gastric tube insertion through the nose
Working procedure
• Hand hygiene and disinfection;
• Check the doctor’s prescription in the patient documentation;
• Check if the aids for inserting the gastric tube are ready and within reach and near the patient;
• Verify the patient’s identity by accessible means;
• Explain to the patient the reason, content and method of procedure and encourage the patient to
cooperate (highlighting the importance of cooperation – the positive influence on the success of
the procedure);
• The patient is placed in a comfortable semi-sitting position (easy for swallowing while the
gravity facilitates easier insertion of the tube);
• Check that the nasal passages are unobstructed;
• The patient is explained the breathing methodology, swallowing during insertion of the tube;
• Protect the patient’s clothing with a drape;
• If possible, the patient holds the kidney bowl;
• Put on protective gloves;
• The approximate length of the tube is determined by measuring from the tip of the nose to the
earlobe and to the end of the sternum - this length determines the approximate distance from the
nasal passage to the stomach;
• Apply anesthetic gel to the end of the tube (local anesthetic - Mesocain gel);
• The tube is inserted during patient permanent swallowing with a small amount of water
(according to their health condition, the patient inhales, exhales and swallows, the tube slowly
shifts by 5-10 cm with each swallowing up to the marker);
• If the patient begins to experience nausea, the insertion is interrupted and the patient is asked to
take deep breaths;
• Constantly monitor the oral cavity so that the tube does not curl up inside;
• Proper insertion of the gastric tube is confirmed by the aspiration of gastric juices using the
Janet syringe by air insufflation and subsequent control of auscultation with a stethoscope (the
most reliable method of verifying the location of the tube is by X-ray);
• Inappropriate – to immerse the end of the tube under water and to watch for an air leak;
• The tube is attached with a strip of tape to the nose or the cheek of the patient;
• The end of the tube is closed or led into a collection bag;
• Washing and disinfection of hands;
• The procedure is recorded.
• In the event of complications with insertion of the gastric tube, terminate the procedure and
inform a doctor;
• The aids are cleaned according to the standard procedure.
Gastric tube insertion through the mouth
The insertion of the gastric tube through the mouth is unpleasant because it can induce vomiting.
Working procedure
• Hand hygiene and disinfection;
• Check the doctor’s prescription in the patient documentation;
• Check if the aids for inserting the gastric tube are ready and within reach and near the patient;
• Verify the patient’s identity by accessible means;
• Explain to the patient the reason, content and method of the procedure and ask the patient to
cooperate;
• The patient is then put in a comfortable sitting position;
• The patient opens their mouth and their tongue is held down with a tongue depressor;
• The tip of the tube is rested on the tongue and the patient is asked to inhale, exhale and
swallow; the tube is gently inserted at the exhale behind the tongue root; this is repeated several
times while the tube is slowly inserted into the digestive tract;
• The next procedure is the same as for insertion through the nose.
Patient care after the procedure
• The patient is put back in the original and comfortable position
• The patient receives information about the next steps with respect to their health condition, the
inserted gastric tube, and the doctor’s prescription
Care of aids after use
Used disposable aids are discarded with other infectious waste; kidney bowls are put into
disinfectant and other aids are cleaned and stored according to standard procedure.
Complications
The following complications may occur with the insertion of the gastric tube:
• The tube may curl up in the patient's mouth during insertion; therefore the nurse monitors the
patient's cavity; if it does occur then pull the tube back slightly until aligned and the insertion can
continue;
• Obstruction of the tube;
• Insertion of the tube into the respiratory tract;
• Awake patient – starts to cough immediately, the tube must be removed immediately;
• Unconscious patient – the correct insertion can be verified by injecting a small amount of air
into the tube (about 20 ml) while listening to insufflation in the epigastrium;
• Tube orifice blocked with gastric content – if the gastric juice does not aspire, it may indicate a
blocked tube with gastric contents; the tube is never rinsed with water but always with air while
listening to insufflation in the epigastrium.
Removing the gastric tube
The tube is exchanged after 3 – 5 days to avoid formation of pressure ulcers on the mucous
membrane. A thin tube can remain inserted for a longer period.
The most reliable method of verifying the insertion of the gastric tube is:
• X-ray
• Aspiration of gastric contents
• Injection of a fluid into the tube and subsequent aspiration
• Free leakage of gastric contents through the tube
• Immersion of the end of the tube under water and monitoring any air leak