❤️ NG Tube Insertion

1.​ Perform hand hygiene and gather supplies.

2.​ Inspect the nasal and oral cavities.
3.​ Assess the most patent nostril.
4.​ Assess the abdomen (inspect/palpate/auscultate).
5.​ Assess level of consciousness and understanding.
6.​ Check the physician's order (type and reason).
7.​ Verify if the tube will be connected to suction or drainage.
8.​ Position the patient in High Fowler's (45–90°) with pillow supporting head and shoulders
9.​ Raise the bed to a comfortable working height.
10.​ Agree on a stop signal with the patient.
11.​ Place a towel on the chest and provide tissues/emesis basin.
12.​ Provide water with a straw (if not contraindicated), dry swallow (contraindicated).
13.​ Stand on the dominant side of the patient.
14.​ Apply sterile gloves.
15.​ Measure the tube (Tip of nose → Pinna of Ear → Xiphoid process) and mark the tube.
16.​ Curve (curl) the distal 10–15 cm of the NG tube around your gloved finger, then release.
17.​ Lubricate the tip of the NG tube with a water-soluble lubricant.
18.​ Have the patient flex the head forward and breathe through the mouth.
19.​ Insert the NG tube slowly into the nostril, directing it along the floor of the nasal passage toward the ear.
20.​ If slight resistance is met, twist gently and continue. If significant resistance occurs, remove and try the other nostril.
21.​ If there’s difficulty, ask the patient to sip water and swallow (or dry swallow if NPO) while advancing the tube.
○​ If gagging/coughing persists, inspect w/ tongue blade + flashlight, check for coiling in the mouth.
22.​ Advance the tube until the marked length is reached.
23.​ Temporarily anchor tube to pt’s cheek until correct placement is checked.
24.​ Verify tube placement acc. to agency policy (pH, then X-ray before feeding)
○​ Aspirate, test using color-coded pH paper.
25.​ Once placement is confirmed, mark and record the external tube length (nose-outer end).
26.​ Secure the tube to the nose and pin it to the gown (leave enough length for head movement).
27.​ Ensure pt is comfortable and maintain the head of bed at 30° or higher.
28.​ Document the procedure acc. to agency policy, report unexpected findings to the doctor.
○​ July 9, 2026, 2:00 PM. 16 Fr single-lumen NGT inserted via R naris using water-soluble lubricant. Tube secured
at 53 cm. Placement confirmed via gastric aspirate pH of 4.0 (clear, light-green fluid). Pt tolerated the procedure
well without coughing or respiratory distress.

Nasogastric Tube Feeding (Gastric Gavage)

1.​ Assess the client's need for enteral tube feedings.
○​ impaired swallowing, decreased LOC, head/neck surgery, facial trauma, upper GI tract surgeries
2.​ Evaluate the client's nutritional status.
○​ baseline weight + lab values, fluid vo. excess/deficit, electrolyte and metabolic abnormalities
3.​ Verify the physician's order for the prescribed formula and frequency.
4.​ Introduce + Explain the procedure to the client.
5.​ Perform hand hygiene + wear clean gloves.
6.​ Auscultate bowel sounds before feeding.
7.​ Prepare the feeding container
○​ check exp. date and integrity, room temperature, shake well, prime tubing, hang on IV pole
8.​ Prepare the asepto syringe and ensure the formula is at room temperature.
9.​ Position the client in High Fowler's or elevate the head of the bed 30°.
10.​ Verify NG tube placement (check pH of gastric aspirate).
○​ Introduce 10 ml of air + auscultate epigastric area (gurggling, whooshing, burborigmi)
○​ NOTE: Auscultation is NO LONGER considered a reliable method. Confirm with X-ray
11.​ Check gastric residual volume.
12.​ Re-instill the aspirated gastric contents (unless contraindicated).
13.​ Flush the NG tube with 30 mL of water.
14.​ Initiate feeding using the asepto syringe/intermittent (bolus) method.
15.​ Initiate feeding using the feeding bag or continuous-drip method and set the prescribed rate.
16.​ After feeding, flush the naso-enteral tube with 30 mL of water, remove gloves, and perform hand hygiene.
17.​ Keep the client in Semi-Fowler's, High Fowler's, or slightly elevated side-lying position for 30–60 minutes after feeding.

Nasogastric Tube Removal

Before removing NGT: verify physician’s order + if ordered to trial clamp, pt should not experience N/V or abdominal
distension during trial

1.​ Verify the physician's order to remove the NG tube.

2.​ Gather the necessary supplies.
3.​ Verify the client's identity (2 pt id), explain the procedure, and position the client in High Fowler's.
4.​ Perform hand hygiene and place a waterproof pad on the client's chest.
5.​ Disconnect the NG tube from the feeding or suction.
6.​ Remove the tape or securing device from the nose.
7.​ Unclip the NG tube from the client's gown.
8.​ Insert 10–20 mL of air into the NG tube.
9.​ Instruct the client to take a deep breath and hold it.
10.​ Kink tube near the naris, remove in one swift, steady motion while wrapping in your gloved hand, dispose.
11.​ Offer tissue or clean the nares and provide mouth care as needed.
12.​ Remove gloves, position the client comfortably, assess comfort, and perform hand hygiene.
13.​ Document the procedure and the client's response.
🧡 Tracheostomy Care
1.​ Gather supplies: tracheostomy care kit, clean gloves, normal saline, hydrogen peroxide, and clean scissors (if replacing
ties).
2.​ Perform hand hygiene and explain the procedure to the client.
3.​ Apply clean gloves.
4.​ Remove the oxygen tracheostomy mask and place it on the client's chest.
5.​ Remove the old tracheostomy dressing and dispose of it with the gloves.
6.​ Loosen the lids of the hydrogen peroxide and sterile saline.
7.​ Open the tracheostomy kit and don sterile gloves.
8.​ Prepare the sterile field by placing the sterile pad beside the kit.
9.​ Place the sterile Q-tips, brush, and gauze on the sterile field.
10.​ Pour hydrogen peroxide into the large compartment and sterile saline into the medium compartment using the non-dominant
(clean) hand.
11.​ Moisten one Q-tip and gauze with hydrogen peroxide and another with sterile saline. Place them in the small compartment.
12.​ Remove the inner cannula by turning it counterclockwise with the clean hand and place it in the hydrogen peroxide.
13.​ Pick up the sterile brush with the sterile hand and pass it by the handle to the clean hand.
14.​ Remove the inner cannula from the peroxide with the sterile hand and cleanse the inside of the tube using the brush.
15.​ Rinse the inner cannula with sterile saline.
16.​ Reinsert the inner cannula into the outer tracheostomy tube using the sterile hand.
17.​ Lock the inner cannula by turning it clockwise until the two blue dots align.
18.​ Clean under and on top of the faceplate with peroxide-soaked Q-tip and gauze.
19.​ Rinse the same areas with saline-soaked Q-tip and gauze.
20.​ Replace the new sterile tracheostomy dressing.
21.​ Remove sterile gloves and apply clean gloves.
22.​ Replace the oxygen tracheostomy mask.
23.​ Dispose of soiled supplies properly.
24.​ Perform hand hygiene.
25.​ Document the procedure.

Tracheostomy Suction
1.​ Preoxygenate the client with 100% oxygen and hyperventilate using an Ambu bag.
2.​ Don sterile gloves (or one sterile glove on the dominant hand if only one is provided).
3.​ Pick up the suction catheter with the dominant hand and the connecting tubing with the non-dominant hand.
4.​ Connect the catheter to the tubing without contaminating the sterile hand.
5.​ Test suction by placing the catheter into sterile saline and occluding the suction port with the thumb.
6.​ Insert the catheter into the trachea through the artificial airway during inspiration.
7.​ Advance the catheter until resistance is felt, then withdraw 1 cm.
8.​ Apply suction while rotating the catheter and withdrawing it over 5–10 seconds.
9.​ Hyperoxygenate and hyperventilate for 1 minute between suction passes.
10.​ Rinse the catheter and tubing by suctioning sterile saline through them.
11.​ Dispose of equipment, remove gloves, perform hand hygiene, and document the procedure.
💚 Surgical Scrub
1.​ Perform hand hygiene and ensure proper OR attire (head cover, mask, eyewear, no jewelry, short nails, no nail polish, skin
intact).
2.​ Adjust the water to a comfortable temperature.
3.​ Turn on the water and obtain the antiseptic solution.
4.​ Wash the hands before beginning the surgical scrub.
5.​ Clean the fingernails under running water.
6.​ Scrub the left hand.
7.​ Scrub the left fingertips (nails).
8.​ Scrub the left arm.
9.​ Scrub the left elbow area.
10.​ Rinse the brush and transfer it to the other hand.
11.​ Scrub the right hand.
12.​ Scrub the right arm.
13.​ Scrub the right elbow area.
14.​ Rinse the left hand and brush.
15.​ Rinse the left arm and elbow.
16.​ Rinse the right hand.
17.​ Rinse the right arm and elbow.
18.​ Complete the scrub using the Time Method or Counted Brush Stroke Method.
19.​ Turn off the faucet using the brush (if the faucet is hand-controlled).
20.​ Walk into the operating room with hands held above elbows.

Drying Hands After Surgical Scrub

1.​ Pick up the sterile towel from the gown pack with a swift, efficient motion.
2.​ Unfold the towel and hold it at the middle without contaminating the sterile gown.
3.​ Bend at the waist to prevent the towel from touching the gown.
4.​ Place one-third of the towel over the right hand and two-thirds toward the left hand.
5.​ Dry the left hand.
6.​ Dry the left arm to the mid-lower arm.
7.​ Transfer the dry end of the towel to the left hand.
8.​ Dry the right hand.
9.​ Dry the right arm to the mid-lower arm.
10.​ Fold the towel into thirds.
11.​ Dry one elbow.
12.​ Transfer the towel, keeping the hands on the underside of the towel.
13.​ Dry the other elbow.
14.​ Discard the towel in the linen hamper.

Remember: Move the hand, not the towel; do not return to dry the same hand; keep hands from touching the part of
the towel that touched the elbows.
🩵 Gowning (Open Glove Technique)
1.​ Reach down to the sterile package and lift the folded gown directly upward (or receive it from the circulating nurse).
2.​ Step back into a clear area.
3.​ Locate the neckband or centerfold.
4.​ Hold the neckband (or centerfold) and gently shake the gown open.
5.​ Slip both hands into the sleeves, keeping the hands at shoulder level without touching the outside of the gown.
6.​ Allow the circulating nurse to pull the sleeves over the wrists.
7.​ Allow the circulating nurse to fasten the back and tie the waistband.

Gowning (Closed Glove Technique)

1.​ Reach down to the sterile package and lift the folded gown directly upward (or receive it from the circulating nurse).
2.​ Step back into a clear area.
3.​ Locate the neckband or centerfold.
4.​ Hold the neckband (or centerfold) and gently shake the gown open.
5.​ Slip both hands into the sleeves, keeping the hands at shoulder level without touching the sterile outside of the gown.
6.​ Allow the circulating nurse to pull the gown on, leaving the sleeve cuffs extended over the hands.
7.​ Allow the circulating nurse to fasten the back, tie the waistband, and close the neck fastener.

Gowning Another Person

1.​ Give the sterile towel to the surgeon without touching the hand.
2.​ Unfold the gown while holding the neckband.
3.​ Hold the gown under the protective cuff and shoulder area, then offer the inside of the gown to the surgeon.
4.​ Release the gown as the surgeon inserts both arms into the sleeves.
5.​ Allow the circulating nurse to pull the gown onto the shoulders and adjust the sleeves and cuffs.

Changing Gown During Operation

1.​ Allow the circulating nurse to unfasten the neck and waist.
2.​ Remove the gown inside out by pulling it off from the shoulders.
3.​ Remove the gown before removing the gloves.
4.​ If only the sleeves are contaminated, apply a sterile sleeve over the contaminated sleeve.
5.​ If necessary, step aside and don another sterile gown.

Removing Gown
1.​ Remove the gown before removing the gloves.
2.​ Loosen the gown cuffs and shake them down over the wrists.
3.​ Grasp the right shoulder with the left hand.
4.​ Pull the gown off the arm, turning the sleeve inside out and away from the body.
5.​ Grasp the opposite shoulder and remove the gown completely inside out.
💙 Closed Glove Technique (Return Demo)
1.​ Using the left hand inside the gown cuff, pick up the right glove by the folded cuff.
2.​ Extend the right forearm with the palm upward and place the glove palm against the right palm.
3.​ Turn the glove cuff over the end of the right sleeve and hand.
4.​ Pull the glove completely over the stockinette cuff.
5.​ Repeat the same steps for the left hand using the gloved right hand.

Open Glove Technique

1.​ Grasp the folded cuff of the right glove with the left hand and pick up the glove.
2.​ Insert the right hand into the glove, leaving the cuff turned down.
3.​ Slip the gloved right fingers under the cuff of the left glove and pick it up.
4.​ Insert the left hand into the glove, leaving the cuff turned down.
5.​ Pull the left glove cuff over the left sleeve cuff without touching the bare wrist.
6.​ Repeat for the right cuff until both gloves are completely on.

Gloving Another Person

1.​ Pick up the right glove with the fingers under the everted cuff.
2.​ Hold the glove with the palm facing the surgeon.
3.​ Stretch the cuff and allow the surgeon to insert the hand without touching it.
4.​ Unfold the cuff over the gown sleeve.
5.​ Repeat the same procedure for the left hand.

Changing Gloves During Operation

1.​ Turn away from the sterile field.
2.​ Extend the contaminated hand to the circulating nurse.
3.​ Allow the circulating nurse to remove the glove inside out.
4.​ Step aside and use the open glove technique (if another sterile team member cannot assist).

Removing Gloves
1.​ Remove the gloves after removing the gown.
2.​ Remove the first glove using the glove-to-glove technique.
3.​ Remove the second glove using the skin-to-skin technique.
4.​ Turn both gloves inside out during removal.