7.4: Sample Documentation
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- Ernstmeyer & Christman (Eds.)
- Chippewa Valley Technical College via OpenRN
Sample Documentation of Expected Findings
Tube Feeding
Patient’s abdomen is soft, nondistended, and bowel sounds are present in all four quadrants. Head of the bed elevated to 45 degrees. Placement of tube verified with measurement of the tube at the nares at 55 cm and gastric aspirate had a pH 4. Patient tolerated 240 mL of tube feeding by gravity followed by a 30-mL water flush.
Tube Irrigation
Irrigated NG tube with 30 mL of water with no resistance. Patient tolerated flush without symptoms.
Tube Suctioning
NG tube connected to low-intermittent suction (LIS) at 60 mmHg. Output from the NGT is green with a volume of 100 mLs in eight hours.
Sample Documentation of Unexpected Findings
Tube Feeding
Patient’s abdomen is soft, nondistended, and bowel sounds are present in all four quadrants. Head of the bed elevated to 45 degrees. Placement of tube verified with measurements of tube at nares at 55 cm and gastric aspirate with a pH of 4. After 100 mLs of tube feeding was infused, the patient complained of feeling full and nauseated. Tube feeding infusion stopped and the head of the bed maintained at a 45-degree angle. Will reassess gastric volume residual in one hour and determine if tube feeding will be resumed.
Tube Irrigation
Attempted to irrigate NG tube with 30 mLs of water, but resistance was felt with procedure. Unable to inject water flush into the NGT. Dr. Smith notified of findings at 1320.
Tube Suctioning
Patient’s abdomen is slightly distended and bowel sounds are hypoactive in all four quadrants. Patient reports increased nausea over the last two hours. NGT connected to low-intermittent suction (LIS) at 60 mmHg. Output from the NGT is mahogany colored with a volume of 800 mLs in eight hours. Dr. Smith notified of findings at 1640.