Hi, I have a pt that has a NG tube. For my GI assessment I know that I have to note that the pt has a NG tube and is on TPN, besides that (and the regulars) is there anything special I should be noting on my GI assessment?
mucouse membranes, bowel tones, how they are handling the feeding, I&O info including your saline flushes if you are aspirating contents to check for placement, then not the color odor, consistency and pH level if you have the pH paper.
Your charting needs to include exactly how you assessed and confirmed that the placement of the N/G tube was in the stomach at the time you did the assessment. (Did you auscultate an air bubble bolused through the tube and hear it in the stomach? Did you aspirate stomach contents, how much and what did they look like? Did you place the distal end of the N/G tube in water and observe for air bubbling that would indicate the tube might be in the air passages?) This is a critical piece of information that MUST be in your narrative charting! Every facility should have a policy directing nurses as to how they want the placement of an N/G tube to be confirmed as being in the stomach. You should know this policy, follow it and your documentation should indicate you followed the policy. The reason this is critical is because if the patient should end up aspirating tube feeding and develop complications, they are going to start looking back through the nurses notes to see who was the last one to chart definite confirmation of that tube being in the patient's stomach, how they confirmed it, and did they follow the hospital policy and procedure. Everyone else who cared for the patient after them is in deep doo-doo and has some 'splaining to do. You should also chart the position of the patient's head as well.