1. Nasogastric aspiration

• Relieve abdominal distension, nausea and vomiting.
• Remove swallowed blood, gastric fluid, or toxic substances when prescribed.
• Obtain gastric aspirate for testing or confirmation of tube placement.
• Assess gastric residual volume only if required by the unit protocol.

1. Verify the prescription/indication and identify the patient.
2. Explain procedure, provide privacy, perform hand hygiene and wear gloves.
3. Position patient upright or semi-Fowler's, if not contraindicated.
4. Check external tube length and tube fixation.
5. Attach a 50-60 mL enteral syringe and gently aspirate. Do not use force.
6. Observe and document amount, colour, consistency, odour, and patient response.
7. Return aspirate or discard it only as per hospital policy and medical order.
8. Flush/close the tube as prescribed and make the patient comfortable.

2. Gastrostomy and jejunostomy feeds

Definitions

• Gastrostomy feeding: Feed is given directly into the stomach through a gastrostomy tube, commonly PEG or surgical G-tube.
• Jejunostomy feeding: Feed is given directly into the jejunum through a J-tube. It is used when gastric feeding is not tolerated or must be avoided.

Indications

• Patient cannot swallow safely but has a functioning gut.
• Long-term enteral feeding requirement.
• Neurological disorders, head and neck cancer, prolonged dysphagia.
• Jejunostomy: severe reflux/aspiration risk, gastric outlet obstruction, delayed gastric emptying, or after some upper GI surgeries.

Important differences

Nursing care and procedure

1. Confirm prescription: formula, volume, route, rate, water flushes, and medicines.
2. Check patient identity and explain.
3. Inspect stoma and tube: redness, swelling, leak, pain, discharge, tube length and securement.
4. Position patient at 30-45 degrees during feeding and for at least 30-60 minutes afterward, according to policy.
5. Use aseptic clean technique, check formula expiry and label the feed.
6. Flush tube with prescribed water before and after feed and medicines, and between medications.
7. Start at prescribed rate. Use a feeding pump for continuous feeds, especially jejunal feeds.
8. Monitor for nausea, vomiting, abdominal distension, cramps, diarrhoea, constipation, leakage, aspiration, dehydration, blood glucose abnormalities, and blockage.
9. Record feed type, volume, rate, flushes, tube-site condition, tolerance, intake-output, and complications.

• Give bolus feeds through a jejunostomy unless specifically prescribed.
• Mix medications with feed.
• Crush enteric-coated, sustained-release, sublingual, or buccal medicines.
• Force water or feed through a blocked tube.

3. Ileostomy and colostomy care

Definitions

• Ileostomy: Opening of ileum onto the abdominal wall. Output is usually liquid to semi-liquid, frequent, and enzyme-rich.
• Colostomy: Opening of colon onto the abdominal wall. Output varies by site, from liquid in ascending colon to more formed stool in sigmoid colostomy.

Normal stoma appearance

• Pink to red, moist, shiny.
• Mild oedema is common immediately after surgery.
• It may bleed slightly on gentle cleaning because it is highly vascular.

Abnormal findings to report immediately

• Pale, dusky, bluish, purple, brown, or black stoma.
• No output with pain/distension, or sudden very high output.
• Severe bleeding, marked retraction or prolapse.
• Peristomal ulceration, leakage, severe redness, rash, or purulent discharge.
• Ileostomy output causing dehydration: thirst, dizziness, low urine output, tachycardia.

Equipment

Procedure

1. Explain, provide privacy, perform hand hygiene and wear gloves.
2. Empty pouch when it is one-third to one-half full.
3. Gently remove old pouch while supporting the skin.
4. Inspect stoma, peristomal skin, output and amount.
5. Clean with warm water and dry thoroughly. Avoid oily creams or harsh products unless prescribed.
6. Measure stoma and cut barrier opening about 1-2 mm larger than stoma.
7. Apply skin barrier and pouch without wrinkles; ensure a leak-proof seal.
8. Dispose equipment safely, remove gloves, perform hand hygiene, and document.

• Encourage adequate fluids, particularly with ileostomy.
• Chew food well and introduce foods gradually.
• Carry spare pouching supplies.
• Seek help for reduced output with cramps, persistent leakage, skin injury, vomiting, or colour change.
• Teach independent pouch emptying and replacement.

4. Surgical dressing

Purposes

• Protect wound from contamination and trauma.
• Absorb blood or exudate.
• Maintain a suitable wound environment.
• Support wound edges or drains.
• Allow observation for bleeding, infection, and wound dehiscence.

Assessment before dressing

• Pain and need for analgesia.
• Dressing condition: dry, intact, soaked, loose, or foul-smelling.
• Wound edges, sutures/staples, redness, warmth, swelling, discharge, bleeding, and odour.
• Drain type, output amount and characteristics.

Basic dressing-change steps

1. Verify order, explain, provide privacy and analgesia if needed.
2. Hand hygiene, prepare sterile field and equipment.
3. Position patient comfortably and expose only the required area.
4. Wear clean gloves to remove old dressing.
5. Observe and document wound drainage and old dressing.
6. Remove gloves, perform hand hygiene, and use sterile gloves or aseptic non-touch technique as per policy.
7. Clean from cleanest area to less clean area, generally from incision centre outward, using one swab for one stroke.
8. Apply prescribed sterile dressing without touching the wound-contact surface.
9. Secure dressing, make patient comfortable, dispose waste safely, and document.

• Rapidly soaking blood.
• Purulent or foul-smelling discharge.
• Increasing redness, warmth, swelling, severe pain, fever.
• Wound separation, protruding tissue, or drain displacement.

5. Suture removal

Approximate timing

Procedure

1. Check prescription, identify patient, explain and assess wound.
2. Gather sterile suture-removal set, gloves, sterile swabs, antiseptic if ordered, and adhesive strips if needed.
3. Position patient and expose wound.
4. Remove dressing and inspect wound for approximation, redness, discharge, swelling, and dehiscence.
5. Clean wound if required.
6. Lift the knot with forceps, cut the suture close to the skin, and pull out gently through the side of the knot.
7. Remove alternate sutures first if wound support is doubtful. Check wound approximation, then remove remaining sutures if safe.
8. Apply Steri-Strips or dressing if prescribed.
9. Document number removed, wound condition, patient tolerance, and any complication.

6. Surgical soak

Purpose

• Prevent surgical-site infection.
• Reduce transfer of microorganisms from surgical team to patient.
• Maintain asepsis before donning sterile gown and gloves.

Basic steps

1. Remove rings, watch, bracelets; nails must be short and clean.
2. Wear cap and mask before starting.
3. Check hands for cuts or infection.
4. Wet hands and forearms under running water, keeping hands higher than elbows.
5. Apply surgical antimicrobial soap or alcohol-based surgical hand rub according to hospital policy.
6. Clean nails with a disposable nail cleaner if required.
7. Scrub fingers, palms, dorsum of hands, wrists, and forearms systematically.
8. Keep hands above elbows so water flows from fingertips toward elbows.
9. Rinse from fingertips to elbows without touching sink or taps.
10. Dry with sterile towel from fingers to elbow, using one side for each arm.
11. Don sterile gown and gloves without contaminating hands.

Important viva points

• Do not touch sink, tap, uniform, hair, mask, or any unsterile surface after surgical hand preparation.
• If contamination occurs, repeat surgical hand preparation.
• Duration and product are according to manufacturer instructions and hospital policy. Alcohol-based surgical hand rub is commonly used when hands are not visibly soiled.
• Surgical hand preparation is different from ordinary handwashing because it is more systematic and must maintain asepsis throughout.