SUBJECT: Nursing Care Guidelines – Gastrointestinal

Guidelines

1. Establishment of nursing assessment at the beginning of each shift, Q4H and

PRN.
• Take note of abdominal history or gastrointestinal complaints and
food allergies.
• Present gastrointestinal.
• Oral assessment.

2. All patients with gastric tubes will be assessed according to unit’s protocol.
• NG tubes will never be inserted by any Nursing Staff to patients with
facial trauma, fractured base of skull and patient with coagulation
problem. Such patients will be referred to the ICU doctor for review.
• NG tubes may be inserted by RN according to Hospital wide policy
and procedure.
• NG tubes placed in to patients with esophageal gastric resection or
reconstruction surgery cannot be removed or repositioned. Label to
denote “no repositioning of tube.”
• Follow the feeding according to unit’s policy and procedure.

3. Establish nutritional assessment every shift and or PRN.

4. Establish fluid volume assessment at least q 2-4H.
5. Provide nursing care like ORAL CARE as guided by unit’s protocol.
6. Manage to identify following complications and provide appropriate
intervention:
• Infection
• Injury
• Alteration in bowel elimination
• Vomiting
• Bleeding e.g. melena, hematemesis, hemopthesis, hematochezia
• Metabolic imbalance

© Cassidy Rabong 2010 Prepared by: SN. CaR

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