Oxygen Administration

Materials:
- Oxygen source (Wall outlet: White [CI-G], Green, [...], oxygen tank or cylinder, portable oxygen tank
- Oxygen gauge with Flow meter
- Appropriate oxygen delivery system (nasal cannula, simple oxygen mask or non rebreather mask)
- stethoscope
- pulse oximeter and probe (if necessary)
- oxygen guard (if oxygen tank is used)

What to do:

  1. Verify the practitioner’s order for oxygen therapy
  2. Confirm the patient’s identity (Name and birthday)
  3. Explain the procedure to the patient, and let him know why he needs oxygen
  4. Do hand hygiene
  5. Gather the needed equipment
  6. Select the most appropriate oxygen delivery device based on the order and the patient’s status.
  7. Assess the patient’s condition, baseline vital signs, and breath sounds, and ensure a patent airway.
  8. Check the patient’s room to ensure safety for administration
  9. Place and Oxygen Precaution sign above the patient’s head and on the door.
  10. Put on personal protective equipment, as needed.
  11. Place the oxygen delivery device securely on the patient, ensuring proper fit.
  12. Adjust the oxygen flow rate as ordered.
  13. Monitor the patient’s response using a pulse oximetry.
  14. if the practitioner has ordered an ABG analysis, check values after allowing sufficient time for the patient’s oxygenation to return to a steady state.
  15. Assess the patient frequently for signs of hypoxia.
  16. Observe skin integrity
  17. Remove and discard your PPE if worn
  18. Do hand hygiene
  19. Clean and disinfect your stethoscope using a disinfectant pad
  20. Do hand hygiene.
  21. Document the procedure.

Enteral Feeding

Materials:

  • Stethoscope
  • Feeding solution
  • Sterile Water
  • Towel
  • Tray
  • Calibrated glass (for flushing solution)
  • Toomey syringe (See image) / Asepto syringe

What to do:

  1. Charge nurse/ Bedside nurse/ Ward Clerk encodes the doctor’s ordered tube feeding solution via Diet Data Entry (include the type of feeding solution, caloric requirement per day, volume per day and concentration)
  2. Charge nurse verifies the feeding bottle/ solution’s label delivered by formula man against doctor’s order sheet, tube feeding card and Kardex and shall check for the following: Type of feeding solution, caloric requirement/ day, concentration (calories/cc)
Nota Bene:
Computation for volume per day and per feeding:
(Caloric requirement per day – 2000 kcal/day)
(Concentration – 2 cal: 1 cc in 6 equal feeding per day. Compute for the volume to be given per feeding)
Formula:
Total caloric requirement per day/ Concentration (calorie/cc)/ # of feeding per day.

Example:
Volume per feeding = 2000kcal/ 2 cal x 1cc
  1. Gather and prepare the necessary equipment and the enteral feeding formula.
  2. Do hand hygiene.
  3. Assess the patient to determine the risk of aspiration and for presence of abdominal distention.
  4. Position the patient to prevent regurgitation/ aspiration of feeding solution according to the following:
Position:
Conscious: Semi Fowler’s (30-45 degree) as tolerated by patient or upright position.
Asleep : Gently wake up the patient and assist in Semi – Fowler’s position
Unconscious: Semi- Fowler’s position
  1. Assess for feeding tube placement before administering the tube feeding and at 4-hour intervals.
Steps for checking tube placement:
* Kink and remove cover of NGT
* Attach the syringe (Toomey) to the NGT
* Place diaphragm of stethoscope at the epigastric area
* Inject 5 ml of air into the NGT
* Listen with your stethoscope for presence of “whooshing” sound
* Aspirate the equivalent amount of air introduced
  1. Place towel over the patient’s neck and chest area
  2. Check for residuals by attaching a Toomey syringe into the port, gently pull back the plunger to aspirate for stomach content. Stop if resistance is felt. Do not use too much force or the tube may collapse.
  3. Re-check for correct NGT placement
Nota Bene:
* If residual formula is > 50 ml. Place in kidney basin, withhold due feeding and refer immediately to the MD.
* If <50 ml., measure gastric content and allow to flow back by gravity. Deduct the volume of the residual from the volume of the feeding solution to be given.
  1. If coffee ground aspirate is noted, hold feeding and refer to the doctor immediately
  2. Document in the I & O under drain column and nurse’s progress notes for quality/ quantity and characteristics (volume) and management done if any.
  3. If no residual is noted, proceed with feeding.
  4. Remove and discard your gloves. Do hand hygiene. Put on new gloves.
  5. Flush the feeding tube with ordered fluid, volume and frequency.
  6. Kink NGT and detach the syringe (Toomey)
  7. Connect the feeding tube bag containing the feeding solution to NGT securely.
  8. Make sure that the feeding bag is installed properly into its enteral pump, with proper data entered. (Volume to be infused and flow rate)
  9. In the absence of an enteral pump, use a feeding bag with a regulator and compute for the desired rate accordingly (drops per minute). Regulate the flow of feeding solution according to doctor’s order.
Formula:
Volume to be infused (volume per feeding) x drop factor/ # of hours x 60 minutes
  1. Hang the feeding bottle to IV stand at the height of not less than 12 -18 inches above the tube’s point of insertion.
  2. Assess for GI intolerance to tube feedings at 4-hour interval. Monitor patient for any signs of aspiration.
  3. After feeding solution has been infuse, remove cover of feeding bottle and flush it with the ordered fluid and volume. Kink and cover the NGT (for intermittent feeding)
  4. For continuous feeding, monitor the patient as often as every hour for complications of feeding.
  5. Instruct the patient/ relative to maintain semi-flower’s position/ upright position for 1 hour to prevent regurgitation.
  6. Wash with soap and water and dry (Toomey Syringe and rinsing glass). Put in a kidney basin/ wrap in ziplock plastic and place inside the bedside table.
  7. Re -assess patient for signs of aspiration/ feeding complications.
  8. Remove your gloves and do hand washing.
  9. Document.
Document:
* Feeding (Nurse’s notes and I/O sheet
* Type of feeding solution
* Caloric requirement/ day
* Residual feeding
* Assessment of patient (Nurse’s Notes)
* Condition of patient before, during and after procedure
* Signs of aspiration and other feeding complications (if any).
* Others (Nurse’s Notes)
* Doctor’s name, time, and response to the referral.
* Feeding time, dose, volume of feeding given.

Capillary Blood Glucose Monitoring

Materials:

  • Novastat CBG Machine
  • Test strip
  • Single use lancet
  • Alcohol swab
  • Cotton ball
  • Diabetic Record (MAR)
  • Operator ID

What to do:

  1. Gather and prepare the appropriate materials
  2. Do hand hygiene. Wear clean gloves.
  3. Confirm patient’s identity. (Name and birthday)
  4. Assess patient’s condition. Ask for patient’s last meal. Make sure the patient had 2 hours fasting for a pre-meals CBG. If the instruction is post-prandial, allow 2 hours gastric emptying time.
  5. Explain the procedure to the patient.
  6. Provide privacy.
  7. Select the puncture site. (Adults: finger, Infant: toe)
  8. Have the patient wash with soap and water and dry them.
  9. Using the machine from the Home Screen, press LOG IN.
  10. Scan the operator ID and press accept.
  11. From Patient Test Screen press ACCEPT.
  12. Scan Strip Lot #, then ACCEPT.
  13. Insert test strip to the bottom of blood glucose meter.
  14. Massage finger/ toe towards the chosen site of puncture. Do not touch the patient’s puncture site.
  15. Clean the intended puncture site with an alcohol pad and let it dry completely.
  16. Using a single-use lancet, placing the lancet perpendicularly to the surface.
  17. Inform that the patient he will feel a pricking pain then push the button to puncture site.
  18. Wipe away the first drop of blood using a gauze pad.
  19. Massage the finger to allow the blood to pool. Touch a drop of blood to the test area on the strip.
  20. Apply pressure to the puncture site using a dry cotton ball, if possible, instruct the patient to maintain pressure.
  21. Results appear in 6 seconds. Record the results in the diabetic record, refer the results if needed. (Refer to Medical Resident on duty or to an Endo Fellow On Duty)
  22. Discard the lancet in a sharps collector. Dispose the test strip in the infectious waste bin.
  23. Remove and discard gloves.
  24. Do hand hygiene
  25. Clean and disinfect the blood glucose meter.
  26. Do hand hygiene.
  27. Administer the appropriate medication or ask the patient to eat if needed.
Blood Glucose Level Chart

Measuring Intake and Output

Materials:

  • Appropriate devices for measuring input (measuring cup, syringe, medication cup, kidney basin or water pitcher)
  • Appropriate measuring container for each type of output being measured, marked in ml.
  • Fluid balance sheet
  • Bedside intake and output worksheet
  • Clean gloves

What to do:

  1. Gather necessary equipment and label with patient’s name
  2. Place the intake and output record (labelled with sources of fluid I&O) and am IV flow sheet, if used in the patient’s medical record.
  3. Perform hand washing.
  4. Confirm Patient’s identity (Name and Birthday)
  5. Explain the process of measuring I&O to the patient and his family.
  6. Alert staff of the need to measure I&O.

Fluid Intake:

  1. Note the time, amount, and type of IV solution or tube feeding on the I&O sheet and on the other appropriate flowsheet.
  2. Measure and record amount of oral fluids ingested, type and amount of instillations and how administered, the amount of medication in liquid, amount of medications and normal saline flushes, amount of medications and water flushes through GI tube.

Fluid Output:

  1. Do hand hygiene.
  2. Wear clean gloves.
  3. Measure urine in graduated container and record
  4. If the patient has an indwelling urinary catheter, open the clamp on the drainage bag, allow urine to flow into the container without touching the drain to the sides of the container and record amount. Close and secure clamp.
  5. Nota Bene* Record: Color, clarity, and odor of urine.

I have few pointers to note as well. It is important to know if the urine of the patient is adequate in comparison with the patient’s fluid intake. Make sure to relay alarming signs to the doctor on duty.

Note: In general for adults, Urine output is adequate if it is 0.5 cc/ kg/ hr. (Dr. Infante, 2020)