The client's NGT drains approximately 400 ml/day of yellow-green drainage and the client begins to complain of nausea. Which does the nurse implement?
1. Irrigate the NGT with 50 ml of water.
2. Assess patency of the nasogastric tube.
3. Replace NGT with a much larger tube.
4. Elevate the client's head and reassess.
2
2. The nurse assesses NGT patency and NGT drainage from the last few hours to gather additional information about the client's nausea. If the NGT drains 400 ml/day, the NGT should drain 15-20 ml/hr, so the nurse can observe for drainage. The nurse also assesses for bowel sounds and abdominal distention because the absence of bowel sounds with abdominal distention indicates impaired peristalsis.
1. The nurse irrigates the NGT after confirming its placement. Tube irrigation helps to prevent accumulated debris that increases the risk of tube occlusion.
3. The nurse avoids relieving the client's problem with a larger-gauge NGT; the nurse inserts a properly sized tube in the client.
4. Raising the head of the bed is a reasonable response to help facilitate gastric emp-tying; however, because the client has an NGT, the nurse should verify tube place-ment first to avoid potential aspiration of gastric contents.
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