Created In order for Cmpleting Remedial Of OSCE Exam

Dedy Chandra H. (102010101006) Medical Faculty Of Jember 2012

1.Sterilisation aspect :

Medical equipments and surgical instruments are examples of devices that are essential to the care of patients; however, because they typically are designed for reuse, they also can transmit pathogens if any of the stepsi nvolved in reprocessing, cleaning, disinfection, or sterilization are inadequate or experience failures. Because the vast majority of pathogens are present in organic matter, e.g. visible soil, the first step in reprocessing, cleaning, is the most important. Any failure to remove soil at this point creates the potential for transmission of infection as the efficacy of subsequent disinfection or sterilization will be compromised. Decontamination is the process by which microorganisms are removed or destroyed in order to render an object safe. It includes: Cleaning, Disinfection, and Sterilization. All hospitals and health care facilities should have a decontamination policy and help staff to decide what decontamination process should be used for which item of equipment.1

Talking about NGT, of course that 3 primary decontamination must elicit into the NGT things. Risks of Infection from Equipment The risks of infection from equipment may be classified into three categories.Placing instruments and equipment into one of the following categories can be helpful in choosing the proper level of disinfection or sterilization needed in order to protect the patients and the health care personnel. Low risk (noncritical items) Noncritical items are items that come into contact with normal and intact skin as stethoscopes or with the inanimate environment (e.g. walls, floors, ceilings, furniture, sinks, etc.). Cleaning with a detergent and drying is usually adequate. Stethoscopes are usually cleaned and in rare cases they should be disinfected if used on infectious patient or highly susceptible patient. Intermediate risk (semi-critical items) Semi-critical items are items that do not penetrate the skin or enter sterile areas of the body but that are in close contact with mucous membranes or with non-intact skin. Cleaning followed by HLD is usually adequate. Examples include respiratory equipment, flexible endoscopes, laryngoscopes, specula, endotracheal tubes, thermometers, and other similar instruments. High risk (critical items)

High risk items are items that penetrate sterile tissues such as body cavities and the vascular system. These items are called critical items because of the high risk of infection if such an item is contaminated with any microorganism before penetrating the tissue. Cleaning followed by sterilization is required. High-level disinfection may sometimes be appropriate if sterilization is not possible, e.g., flexible endoscopes. Single item usage These items may be used in critical, semi-critical, or noncritical areas; however, they are single use items that are prepackaged with the appropriate level of disinfection or sterilization and are disposed of after a single use. surgical instruments, intra-uterine devices, vascular

catheters, implants, etc.1 NGT is come down to the semi-critical items for its harassment contact with the mucous of stomach & single item usage for its useness. All items requiring disinfection or sterilization should be dismantled before cleaning. Cold water is preferred; it will remove most of the protein materials (blood, sputum, etc.) that would be coagulated by heat and would subsequently be difficult to remove. The most simple, cost-effective method is to thoroughly brush the item while keeping the brush below the surface of the water in order to prevent the release of aerosols. The brush should be decontaminated after use and should be dried. Finally, items should be rinsed in clean water and then should be dried. Items are then ready for use (noncritical items) or for disinfection (semi-critical items) or for sterilization (critical items).1 Jump to the method of sterilization in semi-critical items, its about High Level Desinfection method. There are three types of HLD: Disinfection by boiling, Moist heat at 70-100C & Chemical disinfection1 These are the NGT method for disinfectioning. Resume : all of medical equipments, including NGT in order not to making infected by some agents, a process called decontamination that including (cleaning, disinfection, & sterilization ) must be performed regarding to the classification by its risk factor (NGT is an semi critical items). By its method, can make a patient decreased their chance of probability infected certainly using this method should initiated by an awareness of a medical instructor used this equipment with compatible procedure.

2. Classifying NG tube by its colour : Description Length Colour Corflo Nasogastric Feeding Tube 56cm Yellow Corflo Nasogastric Feeding Tube 56cm Yellow Corflo Nasogastric Feeding Tube 56cm Pink Corflo Nasogastric Feeding Tube 92cm Pink Corflo Nasogastric Feeding Tube 92cm Pink Corflo Nasogastric Feeding Tube 92cm Pink Corflo Nasogastric Feeding Tube 92cm Pink Corflo Nasogastric Feeding Tube 92cm Pink Corflo Nasogastric Feeding Tube 92cm Pink Corflo Nasogastric Feeding Tube 92cm Pink Cortrak Feeding Tube 109cm Brown Cortrak Feeding Tube 140cm Green Cortrak Feeding Tube 109cm Brown Cortrak Feeding Tube 140cm Pink Cortrak Feeding Tube 92cm Pink Cortrak Feeding Tube 92cm Yellow Courtesy of : www.merckserono.co.uk/en/therapeutic_areas/gastroenterology/ordering/ordering01.html French Size 6 6 8 8 6 6 8 10 10 12 8 8 10 10 8 10

3.How to Decompresate Gastric :

Gastric Decompression

This is a commonly used NG tube which runs from the nose into the stomach and is routinely used for the removal of gastric fluids and stomach decompression. When deemed necessary, this tube can also be placed orally. The oral gastric (OG) tube is frequently placed in patients with facial fractures or sinusitis. The catheters most commonly used as NG tubes for stomach decompression are of various sizes: number 16 French and number 18 French are the most commonly placed. (Note: The French scale is a scale that is used to denote the size of catheters. One French unit equals 0.33 mm, so an 18 French nasogastric tube is approximately 6 mm) The preferred method for placing a NG tube is at the bedside with the patient in a semiupright position. The NG tubes are generally placed by the attending clinician or trained nursing staff. In order to ensure proper placement, the length of tube that must be inserted should be pre-determined. This is done by taking the end with the access ports and placing it at the tip of the patients nose. Extend the tube up to the ear lobe, then make a bend and extend it down to the xiphoid process, that point should be marked on the tube.2 Although this method of estimation is not foolproof, it is sufficient for the initial placement. After confirming the oral cavity is empty, flexion of the cervical spine will help ensure the NG tube progresses down the esophagus toward the stomach. Always keep spine precautions in check if the patient has a known or suspected spinal injury. Manual stabilization of the head is required to help prevent potential injury to the patient. You should liberally coat the first six inches of the access end of the tube with a water-soluble lubricant which contains a local anesthetic. Insert the tube into the nostril and advance it down to the nasopharynx.

Coughing at this point may indicate passage of the tube into the trachea. If this is suspected, remove or partially withdraw the tube and reinsert it once the patient is comfortable. When the tube is at the pharynx, the patient can be offered a glass of water, and when he/she is swallowing, the tube can be advanced into the stomach. If the physicians have ordered the patient to have nothing per mouth (NPO), the patient may take dry swallows to help the tube advance. The method just described of placing an NG tube requires an alert and cooperative patient. When a patient has limited ability to participate due to trauma or illness, the NG or OG tube can still be placed by the clinician or nursing staff at bedside. If possible, the patients head should be tucked with the chin toward the chest. This manipulation will help prevent the tube from advancing into the airway and the lung. When cervical flexion is ill advised, the patient can be log rolled onto their left side maintaining full spine precautions. Once the tube has been advanced to the marked point, it is time to confirm the position of the tube; it should be located in the fundus of the stomach. This is a critical step in the process as incorrect placement of a NG tube can be dangerous: pneumothorax, hydrothorax, pleural effusions, pneumonia, aspiration of gastric contents, and other complications have resulted from a poorly placed nasogastric tube.3 Reviewing the literature, it is noted that checking the position of the tube can be done by many different methods:

Auscultation technique: 30-60 cc of air is injected through the NG tube while the abdomen is ausculated, the act of listening to sounds made by internal organs. If the tube is in the stomach, the passage of air should be heard by placing a stethoscope over the stomach. Although useful, this method has been shown to be unreliable.4 Aspiration of gastric contents: Gastric contents are aspirated and visually inspected. Again, this method is not reliable; pleural fluid can, at times, take on the appearance of gastric contents. pH testing: Gastric contents are aspirated and the pH level is checked. Gastric fluid has a pH of 1 to 4; intestinal fluid has a pH of 6 to 7. Unfortunately, there is not much quality research that addresses the accuracy of this method.5 As well, the pH of the gastric content aspirated can vary due to medications, age, and gender, also the test itself is subjective when it is done using litmus paper.6 Carbon dioxide measuring: There are several ways to check for carbon dioxide in the NG tube. Capnometry is simple and appears to be very accurate.7 In this method, an end-tidal carbon dioxide detector is attached to the proximal end of the nasogastric tube and the presence (or absence) of carbon dioxide can be confirmed. This test is limited by the availability of the equipment. Water testing: The proximal end of the tube can be submerged in water, and if bubbling is seen, this may be an indication that the tube is in the lung. However, this method cannot be relied on to affirm proper tube placement. Magnet tracking: A small magnet is affixed to the distal end of the nasogastric tube prior to insertion and the position of the tube is ascertained by an external sensor array attached to a computer. One author notes this technique to be 100% reliable.8 Again this technique is limited by the availability of the equipment. Abdominal radiograph: An abdominal radiograph that includes the fundus of the stomach may be taken to confirm proper tube placement.

Once the NG tube position has been confirmed, the tube should be secured to the bridge of the nose with surgical tape. If possible and approved by the facility and clinician, the skin

should be prepped with tincture of benzoin to help the tape adhere. There is commonly a significant length of un-advanced NG tube extending from the patients nose. This is frequently secured to the endotracheal (ET) tube on a vented patient or the hospital gown to reduce the chance of the tube being inadvertently pulled out.

The exact incidence of incorrectly placed NG tubes is not known, but one review of the literature noted that placement failures occurred in 1.9% to 89.5% of adults and in 20.9% to 43.5% in children10 but as mentioned previously, it can be catastrophic. Given the limitations of the bedside methods of determining placement, a radiographic exam is preferred. The NG tubes are visible on an abdominal film, and the proper position can be confirmed. Instant feedback: Although there have been many attempts in the literature to determine an accurate and safe method of determining gastric tube placement, none of these methods is 100% foolproof. Although exposure to radiation is always a concern, given the possibility of serious consequences when a gastric tube is misplaced, an abdominal radiograph should be considered the standard of care for determining proper tube placement.

Source : 1. www.ems.org.eg/esic_home/data/giued_part1/Cleaning.pdf 2. Best C. Nasogatric tube insertion in adults who require enteral feeding. Nursing Standard. 2007;21:39-43. 3. Sweeney J. How do I verify NG tube placement? Nursing 2007. 2007;35:25-27. 4. May S. Testing nasogastric tube positioning in the critically ill: exploring the evidence. British Journal of Nursing. 2007;16:414-418. 5. Williams TA, Leslie GD. A review of the nursing care of enteral feedings tubes in critically ill adults: part II. Intensive and Critical care Nursing. 2005;21:5-15. 6.Araujo-Preza CE, Melhado ME, Gutierrez FJ, Maniatis T, Castellano MA. Use of capnometry to verify feeding tube placement. Critical Care Medicine. 2003;31:1603-1604. 7 Bercik P, Schlageter V, Mauro M, Ralinson J, Kucera P, Armstrong D. Noninvasive verification of nasogastric tube placement using a magnet-tracked system: a pilot study in healthy subjects. Journal of Parenteral and Enteral Nutrition. 2005;29:305-310. 8.Williams TA, Leslie GD. A review of the nursing care of enteral feedings tubes in critically ill adults: part II. Intensive and Critical Care Nursing. 2005;21:5-15.