Question

An 87-year female, with a 3-day history of intermittent abdominal pain, abdominal bloating, and nausea and vomiting, came to the emergency department. She moved from Puerto Rico to join her grandson and his family only 2 months ago and speaks very little English. All information was obtained through her grandson. PMH includes an abdominal hysterectomy 12 years ago and an inguinal hernia repair 2- years ago. She has nod history of coronary artery disease, diabetes or pulmonary disease. She takes only ibuprofen occasionally for mild arthritis. She has no known drug allergies (NKDA). Vital signs are: Blood Pressure 134/84, Pulse 84 beats/minute and regular, Respirations 20/minute and Temperature 97.2º F (36.2 ºC). An IV of D5 ½ NS with 20 mEq KCl at 100 mL/hour is started Nasal O2 at 2 L is also ordered. With some difficulty a nasogastric tube (NGT) is inserted and connected to intermittent low wall suction. The NGT suddenly drains 575 mL and then slows to about 190 mL every hour.

What are some nursing interventions that you would provide based on the above lab values?

Answer 1

Nursing Interventions:

S.No	Nursing Interventions	Rationale
1.	Maintain intake and output chart.	To prevent oliguria.
2.	Check serum electrolytes.	To alert for potassium intoxication.
3.	Maintain cardiac monitoring	To find irregular heartbeat as a result of hyperkalemia.
4.	Assess for signs and symptoms of weakness, fatigue.	To prevent further complications.
5.	Ensure the NG tube is in place.	To prevent irritation.
6.	Check the colour, consistency, amount and odour of the drainage.	To prevent secondary complications.
7.	check the suction apparatus.	To prevent blockage.
8.	Assess the patient for the feeling of fullness, pain, and comfort.	It indicates blockage of suction.
9.	Check for bowel sounds.	To prevent abdominal distension.
10.	Assess the respiratory status.	NG tube may interfere the proper respiration.
11.	Empty the drainage whenever necessary and maintain a record of the amount of drainage.	Documentation may helpful for various reasons.