Republic of the Philippines

CENTRAL MINDANAO
UNIVERSITY
College of Nursing

PERFORMANCE CHECKLIST
"NGT OGT INSERTION"

Name: Sec/Group: Score: Rating: 0

Scal Description Interpretation Assisstance Needed

e
The student demonstrates exceptional performance and mastery of the procedure with
5 Outstanding Without Direction
proficiency, coordination and confidence.
The student demonstrates the step-by-step procedure with efficiency, coordination, With occasional physical or
4 Very
confidence and uses time effectively but failed to mention some of verbal direction
Satisfactory
the rationale.
The student meets the standards or basic requirements of the procedure with partial
3 Satisfactory With frequent verbal and/or
demonstration of skills, inefficient, uncoordinated, misses some steps and rationale
direction
and has delayed time expenditure
The student is unskilled and inefficient considering the prolonged use of time and barely With continuous verbal and/or
2 Fair physical
meets the standard requirements of the procedure.
direction
Needs The student misses most of the steps, without rationale, lacks confidence, coordination and With close mentoring and
1 efficiency and failed to meet the standard requirements of the continuous
Improvement
procedure. verbal and physical direction

Procedure 5 4 3 2 1
Preparatory Phase

1 Verify the medical order for insertion of an NG tube.

2 Perform hand hygiene and put on PPE, if indicated.

3 Identify the patient.

Explain the procedure to the patient and provide the rationale as to why the tube
4
is needed. Discuss the associated discomforts that may be experienced and
possible interventions that may allay this discomfort. Answer any questions as
needed.

5 Gather equipment, including selection of the appropriate NG tube.

6 Close the patient’s bedside curtain or door. Raise bed to a comfortable working
position; usually elbow height of the caregiver. Assist the patient to high Fowler’s
position or elevate the head of the bed 45 degrees if the patient is unable to maintain
upright position. Drape chest with bath towel or disposable pad. Have emesis basin
and tissues handy.
Assessment Phase

7 Measure the distance to insert tube by placing tip of tube at patient’s nostril and
extending to tip of earlobe and then to tip of xiphoid process. Mark tube with an
indelible marker.
Put on gloves. Lubricate tip of tube (at least 2” –4”) with water-soluble lubricant.
8
Apply topical anesthetic to nostril and oropharynx, as appropriate.
9 After selecting the appropriate nostril, ask patient to slightly flex head back against
the pillow. Gently insert the tube into the nostril while directing the tube upward and
backward along the floor of the nose. Patient may gag when tube reaches pharynx.
Provide tissues for tearing or watering of eyes. Offer comfort and reassurance to the
patient.
10 When pharynx is reached, instruct patient to touch chin to chest. Encourage patient
 to sip water through a straw or swallow even if no fluids are permitted. Advance tube
in downward and backward direction when patient swallows.

11 Stop when patient breathes. If gagging and coughing persist, stop advancing the
tube and check placement of tube with tongue blade and flashlight. If tube is curled,
straighten the tube and attempt to advance again. Keep advancing tube until pen
marking is reached. Do not use force. Rotate tube if it meets resistance.

12 Discontinue procedure and remove tube if there are signs of distress, such as
gasping, coughing, cyanosis, and inability to speak or hum.

13 Secure the tube loosely to the nose or cheek until it is determined that the tube is in
the patient’s stomach:
a. Attach syringe to end of tube and aspirate a small amount of stomach
contents.
b. Measure the pH of aspirated fluid using pH paper or a meter. Place a drop
of gastric secretions onto pH paper or place small amount in plastic cup
and dip the pH paper into it. Within 30 seconds, compare the color on the
paper with the chart supplied by the manufacturer.
c. Visualize aspirated contents, checking for color and consistency.
d. Obtain radiograph (x-ray) of placement of tube, based on facility policy
(and ordered by physician).

Apply skin barrier to tip and end of nose and allow to dry. Remove gloves and secure
14 tube with a commercially prepared device (follow manufacturer’s directions) or tape to
patient’s nose. To secure with tape:
a. Cut a 4” piece of tape and split bottom 2” or use packaged nose tape for NG
tubes.
b. Place un-split end over bridge of patient’s nose.
c. Wrap split ends under tubing and up and over onto nose. Be careful not to
pull tube too tightly against nose.
15 Put on gloves. Clamp tube and remove the syringe. Cap the tube or attach tube to
suction according to the medical orders.
Termination Phase

16 Measure length of exposed tube. Reinforce marking on tube at nostril with indelible
ink. Ask the patient to turn their head to the side opposite the nostril the tube is
inserted. Secure tube to patient’s gown by using rubber band or tape and safety pin.
17 For additional support, tube can be taped onto patient’s cheek using a piece of tape.
If a double-lumen tube (e.g., Salem sump) is used, secure vent above stomach level.
Attach at shoulder level.
18 Assist with or provide oral hygiene at 2- to 4-hour intervals. Lubricate the lips
generously and clean nares and lubricate as needed. Offer analgesic throat lozenges
or anesthetic spray for throat irritation if needed.
19 Remove equipment and return patient to a position of com fort. Remove gloves.
Raise side rail and lower bed.
20 Remove additional PPE, if used. Perform hand hygiene.
TOTAL 0 0 0 0 0

Knowledge/Assignment Score 0
Total 110
Data source: BCIT, 2015b; Berman & Snyder, 2016; Perry et a Skills (Video) score
Comments:

Clinical Instructor:
Signature over printed name Date

Rubrics Return Demonstration

Video
Paramete 15 10 8 6 Point
r s
It covers all the topics in
It includes basic knowledge It includes essential information
Content depth with details. The The content includes minor details
about the topic. The content about the topic, but it has some
knowledge on the topic is and it has several mistakes. Most of
and seems to be good. mistakes.
excellent. With rationale the steps have no rationale.
About 70% of the steps have About 40% of the steps
Organizati all throughout the video.
rationale. have rationale.
on
The student use language
The student use language The patient minimally
appropriately and
Use of understandably to deliver understands the language The student use language that confuses
understandable to deliver
Langua information to the patient with being used by the student to the patient on the information being
the information to the
about 70% grammatical error. deliver information with about delivered most of the time.
ge patient with no
40% grammatical error.
grammatical error.

Meets the standards or basic

Demonstrates Able to state and Barely of fails to meet the requirements
requirements of the procedure.
exceptional demonstrate the step-by-step of the performance of the procedure,
Misses some steps and
Executio performance and procedure but failed to
rationale with partial
misses not of the steps, without
n mastery all throughout mention the rationale. rationale. Unskilled and inefficient.
demonstration of skills,
the procedure. Efficient, coordinated, Considerable and prolonged time
inefficient, uncoordinated.
Proficient, coordinated confident. Expedient use of expenditure. Lacks confidence,
Delayed time Expenditure
and confident time. coordination and efficiency.

Timely Submits the output on or Submits the output 3 hours Submits the output 5 hours Submits the output more than 5 hours
submissi before the LATE form the set LATE from the set LATE from the set time.
on deadline. time. time.

SCORE 0