OUR LADY OF FATIMA UNIVERSITY

College of Nursing

Bachelor of Science in Nursing STUDENT NAME

PROGRAM

NCMA 219 RLE YEAR & SECTION

Care of Mother and Child at Risk or Problems
COURSE (Acute and Chronic) INSTRUCTOR
SKILLS LABORATORY DATE

PROCEDURE : INSERTION OF NASOGASTRIC TUBE

EXPECTED OUTCOME : The student should be able to insert nasogastric tube aseptically and correctly.
ASSESSMENT TASK : Return Demonstration
Excep/onal Good Average Poor
Assessment Dimension SCORE
(3) (2) (1) (0)
1. Verify the order indica/ng the Verified the doctor’s Verified the doctor’s Verified the Failed to verify
need for nasogastric tube. order properly and order with minimal doctor’s order the doctor’s
(State the indica/on for accurately. error. improperly and order.
nasogastric tube inser/on) inaccurately.
2. Prepare all the equipment. Gathered materials Gathered materials Gathered Failed to gather
(NG tube of appropriate size needed completely. with liUle /me materials with all materials
plastic or rubber, gloves, non- prepara/on. more /me needed.
allergenic adhesive tape, prepara/on.
asepto syringe, K-Y jelly,
stethoscope, facial tissues,
safety pin and penlight)
3. Greet and iden/fy the pa/ent. Greeted and Performed the two Performed Failed to greet
iden/fied pa/ent by (2) ways of one and iden/fy
asking his/her name iden/fying pa/ent. (1) way of pa/ent.
and checking his/her iden/fying
ID band politely. pa/ent.
4. Explain the procedure. Explained procedure Explained procedure Explained Failed to explain
and its purpose to but lacks some procedure but procedure and
the client clearly and details. in an unclear its purpose.
completely with manner.
client’s consent.
5. Assist client to a high- fowler’s Properly and Placed client Placed client Failed to
position if health permits and skillfully positioned comfortably and in comfortably and posi/oned
support head on a pillow. client comfortably: any preferable in any client properly
5.1. High-fowler’s posi/on with less preferable and
position in bed supervision. posi/on with comfortably.
5.2. Semi-fowler’s maximum
position in bed. supervision.
5.3. Side lying
position to the right
6. Place towel across the chest. Place the towel Place the towel Place the towel Failed to place
across the chest with across the chest with across the chest the towel across
ease. liUle forge^ulness. with some the chest.
forge^ulness.
7. Assess the client’s nares. Performed the Performed the Performed the Failed to
a. Ask the client to procedures with procedures with liUle procedures with perform the
hyperextend the head, and ease. errors. some errors. procedure.
using flashlight, observe
the intactness of the
 tissues of the nostrils,
including any irritations or
abrasions.
b. Examine the nares for any
obstructions. Or
deformities by asking the
client to breathe through
one nostril while occluding
the other.
c. Select the nostril that has a
greater airflow.
d. For infant, obstruct one of
the nares, and feel for air
passage from the other.
8. Prepare the tube. If a rubber Performed the Performed the Performed the Failed to
tube is being used, place it on procedures with procedures with liUle procedures with perform the
ice. If a plas/c tube is being ease. errors. some errors. procedure.
used, place it on warm water.
9. Determine how far to insert Performed the Performed the Performed the Failed to
the tube. procedures with procedures with liUle procedures with perform the
a. Use the tube to mark off the ease. errors. some errors. procedure.
distance from the tip of the
client’s nose to the tip of the
earlobe to the tip of the
sternum.
b. For infants and young
children, measure from the tip of
the earlobe and then to the point
midway between the umbilicus
and the xiphoid process.
c. Mark this length with
adhesive tape if the tube does
not have markings.
10. Insert tube. Performed the Performed the Performed the Failed to
a. Don gloves. procedures with procedures with liUle procedures with perform the
b. Lubricate the tip of the tube ease. errors. some errors. procedure.
well with water soluble lubricant
or water to ease insertion.
c. Insert the tube, with its
natural curve toward the client,
into the selected nostril. Ask the
client to hyperextend the neck,
and gently advance the tube
towards the nasopharynx.
d. Do not hyperextend or
hyperflex the infant’s neck.
e. Direct the tube along the
floor on the nostril and toward the
ear on the side.
f. Slight pressure is sometimes
required to pass the tube into the
nasopharynx, and some client’s
eyes may water at this point. Tears
are a natural body response.
Provide the client with tissue if
needed.
11. Tube meets resistance. Performed the Performed the Performed the Failed to
a. If the tube meets resistance, procedures with procedures with liUle procedures with perform the
withdraw it, relubricate it, and ease. errors. some errors. procedure.
insert it in another nostril.
b. Once the tube reaches the
oropharynx (throat) the client
will feel the tube in the throat
and may gag and retch. Ask
the client to tilt the head
forward and encourage the
client to drink and swallow.
c. If the client gags, stop passing
the tube momentarily. Have
the client rest, take sips of
water to calm the gag reflex.
d. In cooperation with the client
to the tube 5 to 10 cm (2 to 4
in.) with each swallow, until
indicated length is inserted.
e. If the client continues to gag
and tube does not advance
with each swallow.
f. Withdraw it slightly, and
inspect the throat by looking
through the mouth, if so,
withdraw it until it is
traightened, and try to insert
it.
12. Ascertain correct placement of Performed the Performed the Performed the Failed to
the tube. procedures with procedures with liUle procedures with perform the
a. Aspirate stomach contents ease. errors. some errors. procedure.
and check the acidity.
b. Introduce air and listen for
gurgling sound.
c. If the signs do not indicate
the placement in the stomach,
advance the tube in 5 cm (2in) and
repeat the tests.
d. For tubes that are to be
place into the duodenum or
jejunum, advance the tube 5 to 7.5
cm (2 to 3 in) per hour until X-ray
confirms its placement
13. Secure the tube by taping it to Performed the Performed the Performed Failed to
the bridge of the client’s nose. procedures with procedures with liUle the perform the
a. If the client has oily skin, ease. errors. procedures with procedure.
wipe the nose first with alcohol. some errors.
b. Cut 7.5 cm (3in) of tape,
and split it lengthwise at one end,
leaving a 2.5 cm at the end.
c. Place the tape over the
bridge of the client’s nose and
bring the split ends under the
tubing and back up over the nose.
For infants or small children, tape
the tube to the area between the
end of the nares and upper lip, as
well as the cheek.
14. Attach the tube to suction Performed the Performed the Performed the Failed to
source or feeding apparatus procedures with procedures with liUle procedures with perform the
as ordered or clamp the end ease. errors. some errors. procedure.
of tubing. If the tube is
inserted preoperatively, is
usually clamped or it may be
covered with gauze square or
plastic specimen bag and an
elastic band.
15. Secure the tube to the client’s Performed the Performed the Performed the Failed to
gown. procedures with procedures with liUle procedures with perform the
a. Loop the elastic band ease. errors. some errors. procedure.
sound the end of the
tubing, attach the elastic
band to the gown with
safety pin. Or attach a
piece of adhesive tape to
the tube and pin the tape
to the gown.
b. For infants or young
children, restrains maybe
necessary during the tube
insertion and throughout
therapy.
16. Wash hands and Washed hands and Washed hands and Washed hands Washed hands
documenta/on documented the some of the details but most of the but
information about of procedure were details of documentation
the procedure not documented. procedure were was not done.
properly and not
completely. documented.

SCALE:
3 – (EXCEPTIONAL) Works competently and independently at all times
2 – (GOOD) Requires minimum guidance and supervision
1 – (AVERAGE) Requires frequent guidance and supervision
0 – (POOR) Requires close guidance and supervision most of the time

OVERALL SCORE:

Target Raw Score: 48 out of 64. If the raw score is less than 48, repeat the return demonstration.

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FACULTY SIGNATURE OVER PRINTED NAME STUDENT NURSE SIGNATURE OVER PRINTED NAME