| T-Tube Care Posted: 27 Dec 2010 06:17 PM PST 
- Also called a biliary draining tube.
- May be placed in the common bile duct after cholecystectomy or choledochostomy.
- The tube facilitates biliary drainage during healing.
- The surgeon inserts the short end (crossbar) into the common bile duct and draws the long end through an incision in the skin. The tube is then connected to a closed gravity drainage system.
- Post-operatively it remains in place between 7 to 14 days.
Equipment - Graduated collection container
- Small plastic bag
- Sterile gloves and clean gloves
- Clamp
- Sterile 4"x4" gauze pads
- Transparent dressings
- Rubber band
- Normal saline solution
- Sterile cleaning solution
- Two sterile basins
- Providone-iodine pads
- Sterile precut drain dressings
- Hyperallergenic paper tape
- Skin protectant
- Montgomery strips
Preparation of equipment - Assemble the equipment at the bedside
- Open all sterile equipment. Place one sterile 4"x4" gauze pad in each sterile basin
- Using sterile technique, pour 50ml of cleaning solution into one basin and 50 ml of normal saline solution into the other basin.
- Tape a small plastic bag on the table to use for refuse
Procedure - Verify the patient's identity using two patient identifiers, such as the patient's name and identification number.
- Provide privacy and reinforce the explanation of the procedure to the patient
- Wash hands
Emptying drainage - Put on glean gloves
- Place the graduated collection container under the outlet valve of the drainage bag. Without contaminating the clamp, valve, or outlet valve, empty the bag's contents completely into the container and reseal the outlet valve.
- Carefully measure and record the character, color, and amount of drainage.
- Discard gloves
Clamping the T-tube - As ordered, occlude the tube lightly with a clamp or wrap a rubber band around the end. Clamping the tube 1 hour before and after meals diverts the bile back to the duodenum to aid digestion.
- Monitor the patient's response to clamping.
- To ensure the comfort and safety, check the bile drainage amounts regularly.
Nursing Interventions - The T-tube usually drains 300 to 500 ml of thin, blood tinged bile in the first 24 hours after surgery.
- To prevent excessive bile loss over 500ml in the first 24 hours or backflow contamination. Bile will flow into the bag only when biliary pressure increases.
- Provide meticulous skin care and frequent dressing changes since bile is irritating to the skin.
- Monitor for bile leakage, which may indicate obstruction.
- Monitor tube patency and the condition of the site hourly for the first 8 hours.
- Protect the skin edges and avoid excessive taping.
- Monitor all urine and stools for color changes.
- Reinforce with the patient that loose bowel occur commonly the first few weeks after surgery.
- Remind the patient about signs and symptoms of T-tube and biliary obstruction and to report them to physicians.
- Teach the patient how to care for the tube at home.
- Reinforce with the patient that the bile stains clothing and is irritating to the skin.
Complications - Obstructed bile flow, skin excoriation or breakdown, tube dislodgement, drainage reflux, and infection.
Related posts: - Nasoenteric-Decompression Tube Care
- REMOVING A NASOGASTRIC TUBE
- IRRIGATING A NASOGASTRIC TUBE CONNECTED TO SUCTION
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| Nasoenteric-Decompression Tube Care Posted: 27 Dec 2010 06:06 PM PST 
- Is inserted by a physician or nurse practitioner nasally and advanced beyond the stomach into the intestinal tract.
- The patient requires encouragement and support while the tube is in place.
- Care involves continuous monitoring to ensure tube patency, proper suction, and bowel decompression and to detect complications, such as skin breakdown and fluid electrolyte imbalances.
Contraindications - Nasal polyps
- Deviated sputum
- Other obstruction that prevents insertions
Equipment - Suction apparatus
- Container of water
- Intake and output record sheet
- Mouthwash and water mixture
- Sponge tipped swabs
- Water soluble lubricants
- Cotton-tipped applicators
- Safety pin
- Tape or rubber band
- Disposable irrigation set
- Irrigant
- Labels for tube lumens
- Throat comfort measures
Preparation of equipment - Assemble the suction apparatus and set up the suction unit
- Test the unit to make sure that the suction works
Procedure - Verify the patient's identity using two patient identifiers, such as the patient's name and identification number.
- Reinforce the explanation of the procedure to the patient and family and answer questions.
- After tube insertion, have the patient lie on his right side for about 2 hours to promote the tube's passage.
- After the tube advances past the pylorus, the physician or nurse practitioner can advance it 2" per hour.
- After it advances to the desired position, coil excess external tubing and secure it to the patient's gown or bed linens; secure the tubes position by taping it to the patient's face.
- Maintain slack in the tubing so the patient can move safely in bed.
- Remind the patient to call for assistance when getting out of bed.
- After securing to the tube, connect it to the tubing on the suction machine to begin decompression.
- Check the suction machine every 2 hours to confirm proper function.
- Empty the drainage container or mark the drainage level with the time and date every 8 hours. Record output.
- After decompression and before extubation, provide a clear-to-full liquid diet and monitor bowel function.
- Record intake and output to monitor fluid balance.
- Normal saline solution is preferred over water as an irrigant.
- Monitor the patient for signs and symptoms of pneumonia since he may be unable to clear his pharynx.
- Be alert for fever, chest pain, tachypnea, or labored breathing, and diminished breath sounds over the affected area.
- Observe the characteristics of the drainage.
- Provide mouth care frequently and encourage the patient to brush his teeth.
- Lubricate the patient's lip with petroleum jelly.
- Monitor patient for peristalsis.
Nursing Interventions - For Miller-Abbot tube, clamp the lumen leading to the mercury balloon and label it "Do not touch".
- Label the other lumen "suction." Marking the tube may help prevent the accidental instillation of irrigant into the wrong lumen.
- Irrigate the tube with the irrigation set to clear the obstruction.
- If the tube connects to a portable suction unit, the patient may move short distances while the patient moves about.
- For throat irrigation, offer mouth wash, gargles or lozenges.
- Reinforce the explanation of the purpose of the procedure and advise the patient about what to expect during and after insertion
- Remind the patient of the signs and symptoms to report.
Complications - Fluid and electrolyte imbalance, pneumonia, mercury poisoning, and intussusception of the bowel.
Related posts: - IRRIGATING A NASOGASTRIC TUBE CONNECTED TO SUCTION
- T-Tube Care
- REMOVING A NASOGASTRIC TUBE
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| Gastrostomy Feeding Button Care Posted: 27 Dec 2010 05:59 PM PST 
- Is used as alternative feeding device for an ambulatory patient receiving a long term enteral feedings.
- It's approved for 6-month implantation and can replace gastrostomy tubes.
- The button is inserted into an established stoma and lies almost flush with skin; only the top of the safety plug is visible.
- Advantages over ordinary feeding tubes include cosmetic, appeal, ease of maintenance, reduced skin irrigation and breakdown, and less chance of being dislodged or migrating.
- The button has a one-way antireflux valve inside a mushroom dome that prevents leakage of gastric contents; its usually replaced every 3 to 4 months, typically because the antireflux valve wears out.
Contraindications - Intestinal obstruction that prohibits use of the bowel
- Diffuse peritonitis
- Intractable vomiting
- Paralytic ileus
- Severe diarrhea
- Use cautiously in patients with severe pancreatitis, enterocutaneous fistulae, and GI ischemia.
Equipment - Gastrostomy feeding button of correct size
- Obturator
- Water-soluble lubricant
- Gloves
- Feeding accessories
- Catheter clamp
- Cleaning equipment
- I,V pole and pump
Procedure - Reinforce the explanation of the insertion, reinsertion, and feeding procedure to the patient.
- Verify the patient's identity using two patient identifiers, such as the patient's name and identification number.
- Make sure signed consent has been obtained.
Providing feedings through the feeding button - Wash hands and put on gloves; monitor the patient's bowel sounds, if absent, withhold the feeding and notify the physician.
- Attach the adapter and feeding catheter to the syringe
- Clamp the catheter and fill the syringe or bag catheter with formula.
- Open the safety plug and attach the adapter and feeding catheter to the button.
- Elevate the syringe or feeding bag above stomach level, and gravity-feed the formula for 15 to 30 minutes, varying the height as needed to alter the infusion rate.
- Use an administration pump for a continuous infusion or for feedings lasting several hours.
- Refill the syringe before it's empty to prevent air from entering the stomach and distending the abdomen.
- After the feeding, flush the button with 10ml of water.
- Lower the syringe or bag below stomach level to allow burping.
- Remove the adapter and feeding catheter.
- Snap the safety plug in place to keep the lumen clean and prevent leakage if the antireflux valve fails.
- Wash the catheter and syringe or feeding bag in warm, soapy water and rinse thoroughly.
- Clean the catheter and adapter with a pipe cleaner.
- Rinse well before using for the next feeding.
- Soak the equipment weekly.
Nursing Interventions - Keep an extra feeding button at the bedside.
- Once daily, clean the peristomal skin with mild soap and water or providone iodine.
- Clean the peristomal site whenever the feeding bag is spilled.
- Reinforce with the patient how the gastrostomy feeding button is inserted and cared for.
- Remind the patient how to use the button for feedings.
- Reinforce how to clean the equipment and provide peristomal skin care.
Complications - Nausea and vomiting, abdominal distention, exit-site infection, exit-site leakage, and peritonitis.
Related posts: - T-Tube Care
- Urinary Catheter Irrigation
- CHECKLIST FOR EVENING CARE
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