Medical Case Scenario: Nasogastric Tube Insertion And Indwelling Catheter

Mrs. Maria O’Reilly is a 70 year old lady admitted to the surgical ward for an elective left total hip replacement (THR).

Mrs O’Reilly presents with a medical history of Coronary Artery Disease, Hypertension, mild Congestive Cardiac Failure and Type II Diabetes.

The patient lives independently in a unit and is currently able to perform ADL’s unassisted. Mrs O’Reilly’s daughter is very supportive and lives locally therefore

easily accompanying Maria to Doctor’s appointments and assisting with shopping needs.

Mrs O’Reilly performs a blood glucose level three (3) times per day and the readings are predominantly between 5-7mmol.

Mrs O’Reilly has been recently widowed and English is the patient’s second language.

• Tenormin 50mg daily
• Aspirin 100mg daily
• Metformin 500mg TDS
• Frusemide 40mg daily
• Potassium 600mg BD
• Paracetamol 1G QID prn
• Oxycodone 5 – 10mg 6/24ly prn
• Metoclopramide 10mg 6/24ly prn

• BP: 140/85, Pulse: 60bpm, Respiratory rate: 18bpm,   Temperature: 36.6, BGL: 5.0mmol
• Pre-op ECG – sinus rhythm rate 62
• Chest – X-ray – lung fields clear

• Uneventful recovery post L)THR pain is well controlled with oral analgesia.
• The patient tolerates only SOOB for 30 minute intervals, with the assistance of 2 nurses. Currently the patient remains resting in bed.
• Wound dressing remains intact with nil ooze evident. No IVT or IDUC. Patient is tolerating minimal amounts of water orally and is voiding on a bed pan with assistance. Bowel chart indicates no passing of stools post operatively.
• On commencement of the shift Mrs. O’Reilly reports feeling nauseated and states “My tummy feels sore and I feel sick”. On assessment the patient’s abdomen is distended and the patient flinches on palpation. On auscultation there is an absence of bowel sounds.
• Immediately following the nurses’ assessment Mrs. O’Reilly vomits approximately 250mls of bile coloured fluid which has a faecal odour.

• Bp: 135/80, Pulse: 90, Respiratory rate: 22, Temperature: 38, BGL: 7.3mmol. Oxygen saturations 93% on room air.

The nurse reports Mrs. O’Reilly’s condition to the Nurse Unit Manager and the Doctor assigned to the patient. Based on the nurses’ report and Doctor’s assessment of Maria, the Doctor has documented the following orders in the patient’s medical history:

• Patient to be NBM until further review
• Insert size 12 nasogastric tube and place on free drainage with 4/24manual aspirations
• Insert urinary indwelling catheter
• Prepare equipment for commencement of Normal Saline 1000mls IVT
• Commence strict 1/24 FBC

1. Discuss Mrs. O’Reilly’s postoperative potential medical problem and factors which could contribute to the development of this issue.Discuss the rationale for the insertion of a nasogastric tube for Mrs. O’Reilly.
   
   
2. Discuss the ‘best practice’ technique for the insertion of a nasogastric tube. Include in the answer the nursing care required to maintain this appliance using evidence based practice. Ensure that all answers are case scenario specific.
   
   
3. Discuss the best practice technique for the insertion of an indwelling catheter and the potential complications of urinary catheterisation. Use evidence based practice.
   
   
4. Discuss the meaning of advocacy and explain individual strategies one can utilise to advocate for Mrs. O’Reilly when performing nursing interventions.
   
   
5. Discuss potential rationales for each of Mrs. O’Reilly’s use of current medications. The following points should be included in the answer.

• Include the drug family/group, indication and reason for this patient being prescribed this medication
  
  
• Consider potential drug interactions and discuss contraindications relevant to this patient

The potentials medical condition that Mrs. O’Reilly’s may be developing is acute colonic pseudo-obstruction(Niu, Liang, & Zhang, 2017). Acute colonic pseudo-obstruction is one of the large bowel obstruction disorders that do not necessarily involve mechanical obstruction but it is characterized by abdominal distension(Niu et al., 2017). This medical condition is fatal as it can lead to complications such as perforation and abdominal ischemia if not treated. It usually presents to elderly patients and mostly after the abdominal surgical operation as they are at a risk of constipation(Keller & Layer, 2015). Evidence shows that patients who have undergone total hip replacement are at risk of developing pseudo-obstruction due to various reasons. These include elderly and use of opioids analgesics(Keller & Layer, 2015). Mrs. O’Reilly has been prescribed with Oxycodone for pain relief after undergoing elective hip replacement surgery. Oxycodone is an opioid analgesic and given that she is receiving 5 to 10 mg six hourly can contribute to acute colonic pseudo-obstruction(Kopecky, Fleming, Levy-Cooperman, O’Connor, & M. Sellers, 2017). In addition, she is 70 years old of which elderly is another contributing factor to the development of the condition.

A nasogastric tube is medical equipment normally prescribed to patients who cannot feed orally due to unconsciousness, and other medical complication(Weijs et al., 2017). However, the nasogastric tube can also be prescribed to patients who are postoperative as they are always on nil by mouth. In addition, the nasogastric tube can be prescribed to patients with either large bowel or small bowel obstruction for decompression purposes, that is, for suctioning of abdominal content(Ricciuto, Baird, & Sant’Anna, 2015). However, evidence shows that, a patient who has no emesis and has intestinal obstruction does not necessarily need the nasogastric tube insertion.   Mrs. O’Reilly has been indicated with Nasogastric tube as a method of relieving decompressions in the bowels. Given that she has bowel incontinence due to colonic pseudo-obstruction, she cannot pass stool normally and the nasogastric tube will help in removing abdominal contents(Yates, 2017). Other than that, she is experiencing emesis with a stool odor which is a normal symptom of abdominal obstruction.  Patient with emesis cannot take drugs orally and therefore the nasogastric tube is indicated to enhance oral medication intake given that she is receiving oral analgesics for pain management(Yates, 2017).

Before inserting a nasogastric tube to Mrs. O’Reilly, review the care plan and confirm why it is indicated. For this case scenario, the nasogastric tube is indicated for suctioning of abdominal content before further review(O’Sullivan, Blackburn, & Wakai, 2014). Explain to Mrs. O’Reilly the purpose and the reason of inserting a nasogastric tube in order to gain the consent.  After that, prepare the environment and all the necessary equipment for the procedure. This is done through the use of aseptic techniques and ensuring hand hygiene(O’Sullivan et al., 2014). Prepare Mrs. O’Reilly by positioning her in a semi-fowler or sitting position where possible with head supported and slightly flexed and put a protective towel into place(Ahmad, Abdul-Hamid, & Abdul-Hamid, 2015). Since Mrs. O’Reilly is vomiting and has abdominal obstructions, ensure that suction machine is available. Use the 14-16 gauge nasogastric tube and lubricate the end with sterile water or normal saline. Measure the length of the tube and help the patient to swallow by giving a small amount of water by a straw. Swallowing helps in tube insertion as it helps to prevent gagging and vomiting and allows tube smoothly go through the esophagus(Ahmad et al., 2015). Topical vasoconstrictor phenylephrine may help to shrink the nasal mucosa when the passage is obstructed.  While inserting, be aware of the complications of the nasogastric insertions like tube coiling in the mouth, cyanosis, excess pain, and more coughing and sudden onset of abdominal pain. In addition, it is important to understand that a nasogastric tube may go to the trachea and finally to the lungs other than the intended region which is the gastric region(Ahmad et al., 2015). Due to that reason, one should be checking if Mrs. O’Reilly has started showing some respiratory symptoms like coughing or difficulty in breathing.

Current Medications include:

Evidence shows that there are risks involved during nasogastric tube insertion. One of them is that the nasogastric tube might be inserted into the trachea which may lead to complications. Due to that reason, nurses often apply the best practice to prevent such incidents and promote patient safety(Weijs et al., 2017). For the case of Mrs. O’ Reilly, the confirmation of the position of the tube can be obvious as the gastric content will automatically try to come out through the nasogastric tube with a stool odor smell(Ricciuto et al., 2015). Where the gastric content does not try to come out, administer 5mls of sterile water through the tube and aspirate. Measure the pH of the aspirated content using a litmus paper(Shaikh, Patil, Mudali, Gafoor, & Umminnisa, 2010). Gastric content is always acidic and so the color of the blue litmus paper is expected to be red. Other than that, you can confirm whether the nasogastric tube is well inserted by taking her to an X-ray. After confirming that the nasogastric tube is well inserted, secure the tube and document all the procedures done for handing over(Weijs et al., 2017). Always confirm if the nasogastric tube is inside the gastric region before performing any suction or handing over to prevent any complication during care(Shaikh et al., 2010). Major nursing care for patients with nasogastric tube includes confirming the tube is well inserted, performing oral care, cleaning the tube area of suction and reporting any complication observed.

A Foley catheter is usually indicated for patients who have undergone surgery to allow free and easy emptying of urine before covering. Since Mrs. O’ Reilly has undergone an elective hip replacement surgery, she needs an indwelling catheter(Lee & Malatt, 2011). The insertion of an indwelling catheter is a sterile procedure in order to prevent the contraction of urinary tract infection(Cooper, Alexander, Sinha, & Omar, 2014). Evidence shows that the majority of the patients have catheter-associated urinary infections due to two major reasons which include the poor use of aseptic techniques during insertion and prolonged duration of stay with an indwelling catheter. Therefore, in order to prevent catheter-associated urinary tract infection on Mrs. O’Reilly, the sterile procedure should be applied(Shepherd, Mackay, & Hagen, 2017).  Before insertion, she should be informed about the procedure and why it is needed in order to obtain the consent. After she accepted to be put an indwelling catheter, she should be well prepared by positioning her well in a frog-leg pose(Lee & Malatt, 2011). Before insertion, dispense the lubricating gel into the tray and add the cleansing solution over three cotton balls. After that, remove the plastic sleeve from the catheter and put the syringes with sterile water into the port.

Inform the patient the need to give any complains when they feel uncomfortable during the procedure. Using the dominant sterile hand, cover the catheter tip with the lubricant(Cooper et al., 2014). Separate the labia using the non-dominant hand in order to make a good visual of the meatus. Take one cotton wool ball with a forsept and wipe one side of the labia from the bottom to up and discard the cotton ball away from the sterile field. Repeat the procedure to the other side of the labia and take away the cotton ball away from the procedure field. Finally, wipe down the middle using the third cotton wool ball and take it away from the sterile field(Shepherd et al., 2017). After that, wipe all the areas with dry cotton wool balls. Insert the catheter for a length of around three inches and wait to see if the urine start to flow. If the urine starts to flow insert one more inch and inflate the catheter using 10 ccs sterile of sterile water. After that, empty all the urine in a urine port before connecting the catheter to the urine bag(Shepherd et al., 2017). Make sure you cap the urine bag and the catheter is well attached. Inflating the catheter should not be done using normal saline as it forms clots salts that can hinder its removal(Cooper et al., 2014). Take precaution when, inflating the catheter and ask the patient to inform you of any discomfort. This is to make sure no any other area is inflated like the urinary urethra. Always use the sterile techniques at all time with the sterile equipment to prevent urinary tract infections.

Admission preoperative vital signs include:

Nursing care involves advocating for the patient’s rights in the course of treatment. Nursing advocacy is defined as the process by which a nurse preserves human dignity, patients’ equality and freedom from suffering(National Collaborating Centre for Determinants of Health, 2015). A nurse plays a big role in caregiving. He or she communicates with the patients and their relatives about their health and the procedures they will undergo. The nurse should explain to Maria O’ Reilly’s process of nasogastric tube insertion, the advantages and possible complications that are likely to result(Jansson, Nyamathi, Heidemann, Duan, & Kaplan, 2017). By promoting patients equality nurse should realize that all patients are unique attend to them unrestricted by social considerations, economic status, personal attributes or the nature of health problems. Maria O’ Reilly’s condition is not an expectation and for this reason, requires should be handled equally like other patients(Pandya & Myrick, 2013). Nursing as a profession involves the desire to help others. He or she strives to free patients from suffering. This is achieved at emotional, psychological and the physical levels. The patient, in this case, has a number of health problems, for instance, pain which is achieved by giving aspirin. In conclusion, a nurse should strive to integrate all aspects revolving around patient care while at the same time upholding standards. This is done through communication, liaisons, education, interpretation, and caregiving.

Tenormin 50mg daily is a beta blocker drug type normally indicated for a high blood pressure of which it is indicated in this patient due to the fact she has hypertension(Kim, Obara, & Johnson, 2015).

Aspirin 100mg daily is an anti-inflammatory drug that is usually indicated to patients who have pain, fever or any information. However, in this case, scenario aspirin is indicated to Mrs. O’Reilly to reduce the risk of stroke and a heart attack since she has currently undergone surgery(Bullock, Galbraith, & Manias, 2013).  This is due to the fact that, aspirin also acts as a blood thinner thus it reduces blood clotting possibilities. Aspirin is contraindicated to patients using frusemide

Metformin 500mg TDS is an antidiabetic drug that is normally indicated to patients with high blood sugar. This drug is indicated to the patients since she has a history of type 2 diabetes mellitus.

Frusemide 40mg daily is a loop diuretic drug that prevents the body from retaining much water. It is indicated to this patient due to the fact that she has hypertension and mild congestive heart failure. Furosemide is contraindicated to patients with high blood sugars.

Potassium 600mg BD drug is a supplement that is usually indicated to patients with heart problems. However, this drug has adverse effects such as vomiting and nausea(Kim et al., 2015)

Paracetamol 1G QID prn is antipyretic drug indicate for pain relief to the patient

Oxycodone 5 – 10mg 6/24ly prn is an opioid drug indicated for pain relief pain to the patient. However, this drug is contraindicated to patients with bowel obstruction as it acts as a risk factor.

Metoclopramide 10mg 6/24ly prn is an antiemetic drug that is indicated to the patient since she is vomiting. However, this drug is contraindicated to patients with hypertension, and intestinal obstruction(Katzung, Masters, & Trevor, 2015).

References

Ahmad, A., Abdul-Hamid, A., & Abdul-Hamid, A. (2015). Challenging nasogastric tube insertion made easy. Annals of the Royal College of Surgeons of England. https://doi.org/10.1308/rcsann.2015.97.2.162a

Bullock, S., Galbraith, A., & Manias, E. (2013). Fundamentals of Pharmacology. Fundamentals of Pharmacology. https://doi.org/10.1097/00007611-194601000-00025

Cooper, F. P. M., Alexander, C. E., Sinha, S., & Omar, M. I. (2014). Policies for replacing long-term indwelling urinary catheters in adults. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD011115

Jansson, B. S., Nyamathi, A., Heidemann, G., Duan, L., & Kaplan, C. (2017). Validation of the Policy Advocacy Engagement Scale for frontline healthcare professionals. Nursing Ethics. https://doi.org/10.1177/0969733015603443

Katzung, B. G., Masters, S. B., & Trevor, A. J. (2015). Basic & clinical pharmacology. A Lange medical book.

Keller, J., & Layer, P. (2015). [Acute colonic pseudo-obstruction: Ogilvie syndrome]. Medizinische Klinik, Intensivmedizin Und Notfallmedizin. https://doi.org/10.1007/s00063-015-0081-4

Kim, T. K., Obara, S., & Johnson, K. B. (2015). Basic Principles of Pharmacology. Miller’s Anesthesia. https://doi.org/10.1016/B978-0-443-06959-8.00019-4

Kopecky, E. A., Fleming, A. B., Levy-Cooperman, N., O’Connor, M., & M. Sellers, E. (2017). Oral Human Abuse Potential of Oxycodone DETERx®(Xtampza®ER). Journal of Clinical Pharmacology, 57(4), 500–512. https://doi.org/10.1002/jcph.833

Lee, E. A., & Malatt, C. (2011). Making the hospital safer for older adult patients: a focus on the indwelling urinary catheter. Perm J. https://doi.org/10.1117/12.567131

National Collaborating Centre for Determinants of Health. (2015). Let’s Talk: Advocacy and Health Equity. National Collaborating Centre for Determinants of Health. Retrieved from https://collections.stfx.ca/cdm/compoundobject/collection/nccdh/id/2483/rec/30

Niu, Q., Liang, K., & Zhang, C. (2017). Acute colonic pseudo-obstruction caused by acute gastroenteritis: A case report. West Indian Medical Journal, 66(1), 178–179. https://doi.org/10.7727/wimj.2014.296

O’Sullivan, R., Blackburn, C., & Wakai, A. (2014). Topical anaesthesia for nasogastric tube insertion. Cochrane Database of Systematic Reviews, 2014(2). https://doi.org/10.1002/14651858.CD007870.pub2

Pandya, A., & Myrick, K. J. (2013). Advocacy: Wellness and recovery programs: A model of self-advocacy for people living with mental illness. Journal of Psychiatric Practice. https://doi.org/10.1097/01.pra.0000430509.82885.d2

Ricciuto, A., Baird, R., & Sant’Anna, A. (2015). A retrospective review of enteral nutrition support practices at a tertiary pediatric hospital: A comparison of prolonged nasogastric and gastrostomy tube feeding. Clinical Nutrition, 34(4), 652–658. https://doi.org/10.1016/j.clnu.2014.07.007

Shaikh, N., Patil, P., Mudali, I. N., Gafoor, M. T., & Umminnisa, F. (2010). Blind nasogastric tube insertion: Be careful. Qatar Medical Journal, 19(2), 69–71.

Shepherd, A. J., Mackay, W. G., & Hagen, S. (2017). Washout policies in long-term indwelling urinary catheterisation in adults. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD004012.pub5

Weijs, T. J., Kumagai, K., Berkelmans, G. H. K., Nieuwenhuijzen, G. A. P., Nilsson, M., & Luyer, M. D. P. (2017). Nasogastric decompression following esophagectomy: A systematic literature review and meta-analysis. Diseases of the Esophagus, 30(3). https://doi.org/10.1111/dote.12530

Yates, A. (2017). Incontinence and its associated complications: is it avoidable? Nurse Prescribing, 15(6), 288–295. Retrieved from internal-pdf://223.113.250.152/Yates 2017 Continence complications.pdf