[WHISTLING]
- GIRLS, HUH?
YEAH, SAD, HUH?
I TRY TO PRACTICE, BUT I CAN'T DO IT.
I JUST SHAKE MY HUSBAND AND SAY, "WHISTLE FOR ME, WHISTLE."
COS HE'S GOOD AT IT.
ALRIGHT, WE'RE MOVING ON. NEW MODULE.
GREAT JOB ON WOUND CARE.
IT'S STILL BETTER, YOU KNOW, THAT YOU'VE GOT A LITTLE WOUND CARE.
HOLD IT FOR THINKING A LITTLE MORE TACTILE.
HOLD IT, WHAT DID I SAY, THINKING, I DON'T KNOW WHAT I SAID.
IT'S JUST A DIFFERENT CONCEPT AWAY FROM IV'S,
KIND OF, A MORE HANDS-ON AND SO FORTH.
WHO TOLD ME THEIR GOOD STORY, ARE THEY IN HERE?
NO, SOMEONE WHO WAS DOING A WOUND THIS WEEK WITH THE WOUND THERAPIST.
AND IT WAS BIG AND DEEP AND I BELIEVE SHE HAD 2 OR 3 ON HER BODY.
AND SHE'D STAND AT HOME WITH ACTUALLY --
AND, KIND OF, GOES, "WHAT'S THAT WHITE STUFF ALONG THE EDGE?"
AND THE GUY WAS, "I DON'T KNOW."
AND SO THEY GOT A LITTLE APPLICATOR AND SHE STARTED PROBING IT,
SCOOPING AROUND AND SOMEONE HAD LEFT A 2X2 IN THE WOUND
AND THE SKIN HAD COVERED TO THE EDGE OF IT
AND SO THEY HAD TO, KIND OF, DIG IT OUT.
SAID IT SMELT SO FOUL WHEN THEY GOT IT OUT OF THE WOUND.
AND THE GAL JUST LOOKED UP AT HERE AND SAID,
"WELL, HERE'S A GOOD LESSON FOR YOU."
NEVER USE A 2X2 OR PACK A WOUND WITH A 2X2.
SO IT WAS A 2X2, NOT A 4X4, SO SOMETHING REALLY TINY DOWN DEEP INTO A CREVICE.
AND, [INDISTINCT], "I'LL NEVER USE A 2X2."
AND SHE SAID IT WAS SO FOUL AND SO AWFUL.
THE OTHER THING I WOULD JUST MENTION ALONG WITH THAT IS THAT WHEN PEOPLE PACK A WOUND,
THEY NEED TO NOTE WHAT THEY PACKED WITH OR TELL THE PERSON BEFORE
SO THAT THEY KNOW WHAT THEY'RE LOOKING FOR.
I MEAN, EVEN IN SURGERY THEY COUNT THEM UP, YOU KNOW,
TO MAKE SURE WHAT THEY PUT IN, THEY TOOK OUT.
AND IF YOU'RE DOING SOMEONE ELSE'S DRESSING, YOU NEED TO KNOW
WHAT WENT BEFORE YOU TO KNOW WHAT TO GET OUT OF THERE.
SO ANYWAYS, THANK HEAVENS FOR A GOOD STUDENT WHO WAS CURIOUS
AT ASKING BECAUSE THE OTHER GUY WOULDN'T EVEN HAVE PROBED IT EITHER,
BECAUSE SHE WASN'T LOOKING FOR IT. YOU KNOW WHAT I MEAN?
SO, ANYWAYS, I LOVE YOUR STORIES,
I LOVE STORIES, HELPS ME PUT IT ALL IN PERSPECTIVE.
OKAY, WERE MOVING ON, WE'RE MOVING TO NASOGASTRIC INSERTION.
AND WE'RE GOING TO INSERT 2 TUBES.
WE'RE GOING TO INSERT A NASOGASTRIC TUBE INTO AN ADULT,
AND WE'RE GOING TO DO A FEEDING TUBE, AN ORAL GASTRIC TUBE INTO A BABY.
SO, IT ACTUALLY DOES NOT TAKE LONG. IT'S ANOTHER FAST DAY.
WE TRY TO GIVE YOU 2, KIND OF, NICE BACK TO BACKERS
HERE WITH ALL THE TESTING WE'RE DOING.
SO, BE PREPARED TO BE IN AND OUT IN 20 TO --
NO MORE THAN 30 MINUTES, IT'S FAST. WE'LL BE WAY AHEAD BY THE END OF THE DAY.
SO COME EARLY, SO WE CAN GET GOING.
ALRIGHT. BEFORE WE GET GOING, JUST A LITTLE INFORMATION THAT YOU NEED
TO APPRECIATE WHAT YOU'RE DOING.
WE'RE GOING TO PUT A TUBE INTO A CLIENT THROUGH THEIR NARIES
BACK DOWN THROUGH THE NASAL PHARYNX AREA.
THIS IS THE NARIES THROUGH THE NASAL PHARYNX.
AND THEN WE HAVE A LITTLE SPLIT-OFF THAT HAPPENS HERE
OF ESOPHAGUS DOWN TO STOMACH OR TRACHEA.
THE GOAL IS TO STAY IN ESOPHAGUS AND INTO STOMACH,
NOT HAVING A LITTLE DETOUR INTO TRACHEA.
SO I'LL TEACH YOU A COUPLE OF TECHNIQUES OF WHAT TO DO.
WHEN WE DID OUR FEEDING TUBES FIRST SEMESTER, RIGHT, WE HAD TUBES IN
AND WE DID FEEDINGS, THEY WERE NASOGASTRIC TUBES.
IT WAS A TUBE SIMILAR TO THIS THAT GOT PUT IN THROUGH THE NOSE,
DOWN, DOWN, DOWN INTO THE STOMACH, AND WE FED.
NASOGASTRIC TUBES NEED TO BE IN FOR LESS THAN 2 WEEKS.
THEY'RE A SHORT-TERM AND ACUTE CARE INTERVENTION.
TYPICALLY AS THE NASOGASTRIC TUBES IS IN FOR 2 WEEKS FOR FEEDING,
IT'S BECAUSE THEY HAVE AN ACUTE PROBLEM AND OR THEY'RE PLANNING
TO GET TO A FEEDING TUBE OR A GASTROSTOMY TUBE, A STOMACH TUBE.
THESE ARE NOT GOOD FOR LONG-TERM BECAUSE THEY CAN GET INADVERTENTLY PULLED OUT
AND THERE'S A RISK FOR ASPIRATION.
AND BECAUSE THEY'RE SO LARGE THAT THEY CAN TRAUMATIZE
THE TISSUE AND THEY CAN CAUSE SKIN BREAKDOWN AND SOME ULCERATION IN THE NARIES AREA.
AND THAT'S NOT GOOD EITHER.
SO YOU CAN'T JUST LEAVE SOMETHING FOREIGN IN A BODY PART FOR A LONG TIME
WITHOUT THERE BEING SOME KIND OF SIDE EFFECT TO THAT.
SO YOU WANT TO BE THINKING WHAT SIZE IS THAT?
SO, FOR --
LET ME JUST EXPLAIN THE TUBES. THIS IS CALLED A LEVINE TUBE.
THERE IS NOTHING SPECIAL ABOUT IT OTHER THAN IT'S A STRAIGHT TUBE.
IT HAS A RADIOPAQUE LINE IN IT SO THAT WE CAN CHECK WITH X-RAY
FOR PLACEMENT WHICH IS REALLY KEY.
AND IT'S USED PRIMARILY FOR FEEDING,
NOT USUALLY FOR TAKING THINGS OUT OF THE STOMACH.
SO, A FEEDING TUBE, OFTEN CALLED A GAVAGE TUBE.
FEEDING, PUTTING SOMETHING INTO THE STOMACH.
BECAUSE THOSE ARE TRAUMATIC FOR SOMEONE THAT MIGHT NEED IT FOR A LONG TIME,
THEY HAVE, WHAT'S CALLED A DOBHOFF TUBE OR A FEEDING TUBE.
AND I'LL PASS THIS AROUND SO THAT YOU CAN SEE IT. MINE'S GETTING A LITTLE MANGLED.
BUT THE TUBE IS A SOFT WHITE PLASTIC,
VERY SOFT AND MUCH EASIER ON THE NARIES, AND THE PASSAGEWAYS.
IF SOMEONE NEEDS TO HAVE IT A LITTLE LONGER,
THEY DON'T WANT TO HAVE THE SURGICAL PROCEDURE,
THAT PUNCTURE FOR THE GASTROSTOMY TUBE.
TO PUT THIS TUBE IN, THERE'S A GUIDE WIRE ON THE INSIDE
SO YOU -- AND A WEIGHT AT THE BOTTOM,
BECAUSE THEY WANT THIS TO, KIND OF, MIGRATE DOWN INTO THE INTESTINES.
SO YOU PUT IT IN THE SAME WAY, I'M GOING TO TEACH YOU IN A BIT.
AND THEN...
..AT THE END HERE, ONCE IT'S IN PLACE --
[PHONE RINGING]
OH, YOU'RE QUICK. THOUGH, THAT'S GOOD.
- THERE'S [INDISTINCT] IN MY WAY.
- OH, MY HANDS ARE JUST MESSED UP RIGHT HERE.
YOU DISCONNECT THE PIECE, AND MINE IS SO OLD.
AND THEN YOU PULL THE GUIDE WIRE OUT. DON'T PULL IT ALL THE WAY UP.
YOU CAN SEE THAT YOU TAKE THE WIRE OUT AND
WHAT GETS LEFT BEHIND IS THE SOFT, SOFT PLASTIC.
SO YOU DON'T GET THE PRESSURE THAT THIS HARD LEVINE TUBE PUTS ON THE NARIES.
SO YOU CAN USE THESE FOR A LITTLE BIT LONGER.
THESE ARE UNACCEPTABLE TUBES FOR PUTTING IN FOR SOMEONE THAT HAS, FOR EXAMPLE,
A GI BLEED, GASTROINTESTINAL BLEEDING AND ULCERATION,
AND YOU'RE PUTTING A TUBE IN TO SUCTION OUT THINGS.
BECAUSE IT'S TOO THIN, AND IT WILL CLOT OFF.
AND SO, IT'S ONLY FOR FEEDING, ONLY FOR PUTTING THINGS IN,
ONLY FOR A LONGER-TERM FEED SITUATION.
DOBHOFF, SOFT...
..WEIGHTED, GOES DOWN TO THE INTESTINE AND I'LL PASS THAT AROUND.
IF YOU HAVE A FEEDING TUBE OR WHICH IS A DOBHOFF
OR A LEVINE TUBE FOR FEEDING, THEY'RE GAVAGING.
WE PUT TUBES IN FOR OTHER REASONS, THOUGH.
I ALLUDED TO A GI BLEED, WE NEED TO GET SOMETHING OUT OF THE STOMACH.
THEY MAY TAKE TOO MANY PILLS, SUICIDE ATTEMPT OR JUST A MISTAKE, A CHILD.
AND SO WE LAVAGE THE STOMACH.
WE PUT A TUBE DOWN INTO THE STOMACH AND THEN WE INSTILL FLUIDS,
NORMAL SALINE AND PULL OFF THE STOMACH CONTENTS
TO GET WHAT'S IN THE STOMACH OUT OF THE STOMACH.
AND THAT'S CALLED LAVAGING.
OR, I THINK IN SPANISH, I THINK IT'S LA WASHING, IT'S A WASHING,
IT'S A CLEANING, LAVAGE.
WE ALSO PUT THE TUBE IN FOR A THIRD REASON,
VERY SIMILAR TO LAVAGING, WE'RE TRYING TO GET SOMETHING OUT.
BUT WE'RE TRYING TO HELP THE INTESTINES AND IT'S CALLED DECOMPRESSION.
SOMETIMES, THERE'S A BLOCKAGE IN THE BOWEL
FOR WHATEVER REASON, CANCER, STOOL, SURGERY
AND THE INTESTINES AREN'T MOVING ALONG LIKE THEY SHOULD.
AND IF THINGS GET, KIND OF, BOUND UP IN THERE,
THE CLIENT GETS VERY DISTENDED, THEY GET BLOCKED UP
AND THEY MAY HAVE NAUSEA AND VOMITING,
AND THE STOMACH NEEDS A REST.
THE STOMACH IS STILL GOING TO PRODUCE JUICES, RIGHT.
EVEN THINKING ABOUT A DOUGHNUT, CHOCOLATE, PIE,
YOU SALIVATE AND IT STARTS RUNNING AND YOUR SYSTEM CREATES JUICES.
AND WE NEED TO KEEP THOSE JUICES FROM GOING DOWN INTO THE INTESTINES
BECAUSE THE CLIENT CAN'T MOVE THOSE ALONG.
SO WE'LL PUT A TUBE DOWN FOR DECOMPRESSION.
I NEED YOU TO APPRECIATE ALL OF THAT BECAUSE YOU NEED TO KNOW WHY YOUR CLIENT NEEDS THE TUBE
SO THAT YOU CAN PICK THE RIGHT TUBE AND THE RIGHT SIZE TUBE.
IF YOU'RE JUST GOING TO PUT A TUBE IN FOR FEEDING,
LEVINE IS APPROPRIATE.
BUT IF YOU'RE GOING TO BE PUTTING YOUR CLIENT --
A TUBE DOWN YOUR CLIENT,
AND YOU'RE GOING TO BE SUCKING CONTENTS OUT
FOR A LONG TIME TO GIVE THE STOMACH A REST FOR DECOMPRESSION,
WE USE WHAT'S CALLED A SALEM SUMP TUBE.
IT'S A TUBE THAT LOOKS VERY MUCH LIKE THE LEVINE TUBE, IT'S STILL A TUBE.
BUT WHAT COMES OFF OF IT IS AN AIR VENT OR THE SUMP, IF YOU WILL.
AND WHAT THIS DOES IS THAT THERE'S ANOTHER LUMEN IN THE TUBE
AND IT ALLOWS AIR TO VENT OUT OF THE TUBE
SO THAT THE TUBE DOESN'T ADHERE TO THE STOMACH LINING.
WHEN WE HOOK THIS PIECE UP TO SUCTION,
IT WILL -- IT CAN STICK AND SUCK ON TO TISSUE
AND CAUSE FURTHER DAMAGE AND WE DON'T WANT THAT TO HAPPEN.
SO THE LEVINE PIECE ALLOWS FOR AIR TO ESCAPE
SO THAT YOU DON'T GET SUCTION AND TEARING OF THE MUCOSA OF THE STOMACH.
ALL OF THAT IS DESCRIBED VERY EXCELLENTLY
IN THE FIRST COUPLE OF PARAGRAPHS
OF YOUR OCHEM BOOK OF NASOGASTRIC TUBES.
AND IT'S GOING TO DISCUSS ABOUT THE USE FOR DECOMPRESSION
FOR FEEDING AND FOR REMOVING FLUIDS.
I DON'T KNOW -- I CAN'T REMEMBER THEM USING THE WORDS LAVAGE AND GAVAGE.
BUT YOU NEED TO KNOW WHAT THOSE WORDS ARE
BECAUSE THAT'S THE MEDICAL TERMINOLOGY FOR IT.
SO THIS TUBE WOULD GO IN THE SAME.
BUT -- OOPS. NOT DOWN THE MOUTH, THAT WOULD BE ORAL.
YOU KNOW WHAT, THIS ONE WON'T FIT. UH-HUH.
PAUSE. THROUGH THE STOMACH.
THEN WHAT YOU DO IS CONNECT IT TO THE SUCTION OR PLUG IT DEPENDING ON WHAT THE NEED IS.
AND I'LL SHOW YOU HOW TO DO THAT IN A MINUTE.
THE TUBES COME IN DIFFERENT SIZES.
WE'VE TALKED ABOUT GAUGES AND THE BIGGER THE NUMBER ON A GAUGE...
..THE SMALLER THE NEEDLE.
BUT WE'RE NOW WORKING WITH FRENCHES.
AND THESE COME IN A FRENCH SIZE.
AND SO THIS PARTICULAR TUBE IS A 14 FRENCH
AND THAT WOULD BE THE SMALLEST SIZE
THAT YOU WOULD EVER WANT TO LAVAGE OR DECOMPRESS SOMEONE WITH.
BECAUSE, IN LAVAGING AND DECOMPRESSING, WE'RE PULLING OUT STUFF.
AND WE NEED IT TO BE WIDE ENOUGH, HAVE A THICK ENOUGH LUMEN
THAT STUFF WILL COME OUT WITHOUT BLOCKING IT UP.
THIS LUMEN IS A 16 AND IT'S A LITTLE BIG FOR MY LITTLE MANNEQUIN HERE.
AND THAT'S A PRETTY AVERAGE SIZE.
SO 14-16 WOULD BE THE LUMEN SIZE THAT YOU WOULD PICK
FOR YOUR AVERAGE DECOMPRESSION BLEEDING SCENARIO.
IF THERE'S SOMETHING ELSE,
MAYBE PILLS THAT ARE LARGE OR SOMETHING, YOU COULD GO UP TO AN 18 OR 20,
BUT VERY RARELY DO WE -- 14 AND 16, BECAUSE
REMEMBER, YOU'RE PASSING IT THROUGH TERMINATES.
WELL, ACTUALLY NOT THE TERMINATES, THROUGH THE NARIES.
YOU DON'T WANT TO GET IT IN THE TERMINATES. AND IT'S A SMALLER PASSAGE HERE.
AND YOU CAN'T GO LIKE A FOLEY CATHETER.
WE CAN GO UP TO LARGE FRENCHES, COS THAT'S STRETCHY ANATOMY.
BONES AREN'T STRETCHY ANATOMY,
AND SO YOU'RE LIMITED IN SIZE HERE.
YOU DON'T WANT TO GO LESS THAT 14,
AND USUALLY 14 TO 16 IS ACCEPTABLE
FOR YOUR SIZES OF FRENCH, OKAY, TO PASS STUFF THROUGH.
WHEN WE HOOK SOMEONE TO SUCTION
YOU'RE PULLING OUT OF GASTRIC CONTENTS, RIGHT.
WHAT DO YOU REMEMBER ABOUT GASTRIC CONTENTS WHEN WE WERE DOING FEEDINGS?
- THEY'RE ACIDIC.
- THEY'RE -- THEY HAVE ELECTROLYTES IN THEM
AND WE WOULD REPLACE THEM TO PROVIDE BALANCE FOR THAT CLIENT.
SO HOW DO YOU BALANCE A CLIENT IF YOU'RE SUCKING EVERYTHING OFF?
- IV. - IV FLUIDS.
SO, MAYBE TPN, BUT MAYBE SOME KIND OF A SOLUTION WITH ELECTROLYTES ADDED TO IT.
AND MAYBE AS SIMPLE AS POTASSIUM, MAYBE A D FIVE AND A HALF SOLUTION WITH POTASSIUM,
SOMETHING THAT GIVES A LITTLE BIT OF BALANCE
DEPENDING ON WHATEVER YOUR CLIENT SCENARIO IS.
SO, WHENEVER ANYONE HAS TO SUCTION WITH AN NG,
THEY HAVE TO HAVE IV SUPPLEMENT
BECAUSE YOU'VE GOT TO BE BALANCING ELECTROLYTES
PLUS THEY NEED SOME NUTRITION, SOME HYDRATION
BECAUSE WE'RE SUCKING EVERYTHING OFF OF THE STOMACH.
THE OTHER THING TO REMEMBER ABOUT SUCTION IS
YOU NEVER DO A CONSTANT SUCTION.
BECAUSE IF YOU DO, THEN YOU JUST TRAUMATIZE THAT TISSUE AS WELL.
SO, IT'S CALLED INTERMITTENT SUCTION.
AND THERE'S A DIFFERENT APPARATUS, I DON'T HAVE ONE IN HERE.
BUT THIS SUCTION IS CONTINUOUS AND I'LL SHOW YOU THAT IN A MINUTE.
YOU WANT US -- IT'S EITHER CALLED GOMCO OR INTERMITTENT.
AND WHAT IT DOES IS IT SUCTIONS...
..AND IT CLICKS OFF.
AND IT CLICKS OFF. AND SO YOU HEAR THAT FUNNY OFF AND ON SOUND GOING
THE WHOLE TIME THAT IT'S RUNNING. BUT IT PUTS THE ANATOMY AT REST.
SO IT'S JUST NOT SUCKING UP DRY, IF YOU WILL.
OKAY, THAT'S OUR THEORY.
WHAT WE NEED TO DO IS APPRECIATE THAT OUR CLIENT HAS --
WHAT SHOULD WE HAVE WRONG WITH OUR CLIENT?
OUR CLIENT IS A GI BLEED, LETS JUST SAY.
WE'RE GOING TO CONNECT OUR CLIENT TO LOW SUCTION,
JUST SO THAT WE HAVE A SCENARIO, OKAY.
WHAT WE WANT TO DO IS GET OURSELVES ORGANIZED HERE.
AND THEN WE GO.
OKAY, THE FIRST THING I'M GOING TO DO
IS CHECK MY DOCTOR'S ORDER, AND SEE THAT AN NG IS ORDERED.
YOU CANNOT JUST PUT A TUBE DOWN SOMEONE
BECAUSE YOU KNOW THEY'RE THROWING UP, YOU KNOW THEY'RE SICK TO THEIR STOMACH,
YOU KNOW THEY'VE GOT AN ULCER AND YOU JUST CAN'T PUT IT DOWN.
IT'S INVASIVE AND YOU CAN'T DO IT.
AND I FIND THAT VERY INTERESTING, ESPECIALLY WHEN I LOOK AT ONE OF THE ARTICLES
I'M GOING TO REFER TO HERE IN A SECOND, AND THAT IS,
THE NEXT THING I WANT TO DO IS MAKE SURE
THERE'S NO CONTRAINDICATIONS FOR PUTTING THIS TUBE IN.
WE TALKED A LITTLE BIT LAST SEMESTER ABOUT THE TUBE
THAT GOT PUT INTO THE BRAIN.
LIKE, THIS IS THE ARTICLE ABOUT THAT, FINALLY.
AND LET ME JUST SEE WHAT THE TITLE OF IT IS.
IT'S BEAUTIFUL AND THE PICTURE IS THERE TOO.
I GAVE YOU WONDERFUL ARTICLES.
'INADVERTENT INTRACRANIAL NASOGASTRIC TUBE PLACEMENT.'
IT TALKS ABOUT THE CASE. AND THEN ON THE SECOND PAGE,
YOU CAN SEE THE TUBE COILED UP INTO THE BRAIN.
WHAT WAS INTERESTING ABOUT THIS CASE WAS...
..IT SHOULD NEVER HAVE BEEN DONE BECAUSE THERE NEVER WAS A DOCTOR'S ORDER.
WHAT -- WHATEVER POSSESSED THIS WOMAN TO PUT THAT IN IS JUST BEYOND ME.
I'D READ THE FIRST OF THE ARTICLE
AND I SAT DOWN A COUPLE OF NIGHTS AGO AND I READ THE WHOLE THING,
JUST TO GET MYSELF CURRENT, YOU KNOW, I READ STUFF,
AND YOU JUST GOT TO REREAD YOUR STUFF.
AND I READ TO THE VERY END AND I WENT, "NO WAY."
SHE DIDN'T EVEN HAVE AN ORDER,
ON TOP OF EVERYTHING ELSE SHE DID WRONG.
OKAY. SO, THE OTHER THING THAT THEY DISCOVERED,
AND MAYBE IT WASN'T SUCH COMMON KNOWLEDGE,
BECAUSE THEY DIDN'T TEACH THIS TO US IN SCHOOL,
IS THAT SOMEBODY THAT'S HAD --
THEY HAD A PITUITARY PROBLEM. AND TO GET INTO THE PITUITARY,
THEY WENT IN THOUGH THE SPHENOID WOUND.
AND WHENEVER YOU HAVE THAT KIND OF SURGERY,
THAT KIND OF CLIENT CAN'T HAVE A NASOGASTRIC TUBE
BECAUSE THERE'S A BREAK IN THE BASE OF THE SKULL,
AND THERE'S A POSSIBILITY FOR TUBES TO GET THROUGH.
JUST THE SAME AS IF YOU HAVE CRANIAL SURGERIES,
NASAL MAXILLARY SURGERIES,
THOSE ARE HIGH RISK CLIENTS AND SHOULDN'T --
OR SHOULD BE CONSIDERED AT RISK FOR HAVING A TUBE,
AND YOU WOULD ALWAYS WANT TO CLARIFY THAT WITH THE PHYSICIAN.
SO, WE NEED TO THEN CHECK AND MAKE SURE OUR CLIENT
DOESN'T HAVE ANY CONTRAINDICATIONS BEFORE THE TUBE GETS IN,
AND FOR SURE, A DOCTOR'S ORDER.
I JUST CAN'T IMAGINE WHY ANYONE WOULD DO THAT.
OKAY. IN ADDITION TO NOT HAVING AN ORDER,
AND TO PUTTING THE TUBE IN, WHEN SHE CHECKED FOR PLACEMENT,
AND YOU DON'T HAVE TO CHECK FOR PLACEMENT, SHE DIDN'T CHECK FOR PA.
SHE CHECKED WITH AIR BY PUTTING 30 CC'S OF AIR
AND LISTENING FOR THE WHOOSH IN THE STOMACH WHICH IS THE OLDER WAY THAT WE USED TO DO IT.
PROBABLY HOW YOU'RE SEEING THEM DO IT, SOME IN THE COMMUNITY.
AND SHE CLAIMED THAT SHE HEARD AIR.
PROBABLY WHEN SHE PUT THE AIR INTO THE BRAIN,
SHE CAUSED, THEY CALLED IT A CORTAL -- PNEUMO CORTAL THORAX OR SOMETHING.
NO, THAT'S NOT THE RIGHT WORD. OH, WELL, LOOK IT UP.
IT'S AIR, THE PNEUMO PART IN THE BRAIN, THE CORTAL PART.
SO AIR IN THE BRAIN CAUSED LIKE A CLOT IN THE BRAIN FOR STROKING.
SO THE AIR DIDN'T HELP. AND THEN THEY DID SOME FEEDING.
ON TOP OF ALL OF IT.
- BRAIN FOOD?
- HUH? BRAIN FOOD, YEAH.
KILLED HER. SO, ANYWAYS.
IT MADE ME WONDER WHY WEREN'T THE OTHER CHECKS MADE.
WHAT OTHER CHECK WOULD HAVE BEEN A GOOD CLUE THAT YOU'RE IN THE RIGHT PLACE?
MAYBE LOOK DOWN THE THROAT AND SEE IF THE TUBE WAS BACK THERE.
BECAUSE, RIGHT, IF IT'S SUPPOSED TO GO THROUGH THE NARIES,
THROUGH THE NASAL PHARYNX, GAG, GAG,
AND THEN GO DOWN THE ESOPHAGUS,
YOU SHOULD SEE TUBE IN BACK OF THROAT.
NONE OF ANY OF THAT STUFF EXISTED
EXCEPT FOR THIS REFERRED BREATH SOUND --
AIR SOUND THAT THEY CLAIMED THEY HEARD.
PROBLEM. SO WE ARE GOING TO PUT IN AN NG WITHOUT ANY OF THAT NONSENSE.
WE'RE GOING TO DO IT RIGHT AND MAKE SURE THAT WE'RE IN THE RIGHT PLACE.
SO WE CHECKED OUR ORDERS, WE KNOW IT'S NOT CONTRAINDICATED,
WE HAVE A DIAGNOSIS. WE'RE GOING TO GATHER UP EQUIPMENT.
SO FIRST THINGS FIRST, I GATHERED UP...
..SUCH A TUBE. AND WE JUST HAVE FEEDING TUBES,
SO THEY'RE ALL GOING TO BE 14 FRENCH LEVINE TUBES.
ALRIGHT. SO THEY PROBABLY DON'T EVEN HAVE ANY BAGS ON ANYMORE.
BUT I HAVE MY TUBE. THIS IS A CLEAN PROCEDURE.
IT'S NOT IN ANY WAY STERILE. SO YOU CAN HANDLE YOUR EQUIPMENT,
MAKE SURE YOUR HANDS ARE GOOD AND WASHED IN THE GATHERING PART.
I HAVE A CHUX THAT I'M GOING TO PUT OVER THE CHEST OR A TOWEL
BECAUSE IN THE PROCESS THEY MAY THROW UP.
BECAUSE OF THE GAGGING AND SOMETIMES RETCHING.
SO HAVE SOMETHING TO PROTECT THE CHEST.
I WANT TO HAVE SOME ICE CHIPS OR SOME WATER AND A STRAW.
THINK ABOUT THIS, IF I'M STUFFING SOMETHING UP THEIR NOSE, CAN THEY DRINK?
THAT'S IN THE WAY. SO THEY NEED SOMETHING SO THAT THEY CAN DRINK.
OTHERWISE, IT JUST DOESN'T HELP.
SO DRINKING HELPS THE TUBE GO DOWN. SO, WE'RE GOING TO GET THAT.
I HAVE MY PH PAPER, I HAVE THE SYRINGE THAT I'M GOING TO CHECK WITH.
MAKE SURE THAT YOU HAVE A CATHETER TIP SYRINGE
BECAUSE THAT'S ALL THAT WILL FIT INTO THAT BOTTOM OF THE TUBING.
WHOA!
I HAVE TAPE THAT I NEED TO GET READY.
AND YOU'RE GOING TO NEED TO GET A COUPLE OF PIECES.
AND THIS IS HOW THEY NEED TO LOOK. ABOUT 4 INCHES LONG.
AND THEN YOU WANT TO TAKE AND SPLIT TO ABOUT 1 INCH.
SO LEAVE ONE INCH INTACT AND SPLIT THIS HALF. YES.
- MY CLIENT IS A [INDISTINCT].
- INTERESTING, YOU'LL SEE A LOT OF GADGETS OUT THERE.
AND THEY DO HAVE A TUBE,
A NASAL GASTRIC HOLDER
AND IT'S A LITTLE PIECE OF, KIND OF, ADHESIVE HERE
THAT HAS A LITTLE RING THAT HOLDS ON.
SO THERE'S ALL KINDS OF LITTLE GADGETS TO HOLD.
HOW DID THEY DO IT WITH TRANSPARENT -- WHAT WAS ON THE TUBE?
- JUST, KIND OF, WRAPPED IT AROUND THE TUBE, TUCKED UNDER THE NOSE.
- HMM, INTERESTING, WHATEVER. IF IT WORKS.
I DON'T WANT TO BE TOO CRITICAL ON THAT ONE.
OKAY, THEN YOU HAVE ONE OTHER PIECE TO GO ACROSS THE NOSE.
BECAUSE THE NOSE IS A T-ZONE AREA AND IT CAN BE PRETTY OILY,
YOU MIGHT WANT TO CONSIDER CLEANING IT AND THEN PUTTING THAT
BARRIER FILM ON HERE, THE NON-STAIN, BUT A LITTLE BARRIER FILM
SO THAT THE OILS DON'T CAUSE EVERYTHING TO SLIP RIGHT OFF.
I HAVE A STETHOSCOPE BECAUSE I DO WANT TO LISTEN
TO THE LUNGS AND THE BOWEL SOUNDS BEFORE I GET GOING AND CHECK IT.
I WANT A FLASHLIGHT SO THAT I CAN LOOK IN THE BACK OF THE THROAT
AND SEE IF I GOT A TUBE BACK THERE.
YOU NEED SOME KIND OF CONNECTOR FOR YOUR SUCTION EQUIPMENT.
IF YOU'RE GOING TO CONNECT YOUR TUBING TO SUCTION,
THEN YOU NEED THIS PIECE THAT'S TAPED TO ON BOTH ENDS.
SO I WOULD HAVE MY TUBING AND MY SUCTION AND HAVE A CONNECTOR
SO THAT I CAN CONNECT WHEN IT'S TO THE CLIENT AND THEN SUCTION.
OR YOU NEED A PLUG IF IT'S FOR A FEEDING TUBE...
..OR SOMETHING. SO, ONE OF THE TWO THINGS YOU NEED TO GET FOR YOUR NG.
AND I HAVE A SAFETY PIN, SO I CAN PIN ON TO THE GOWN
WHICH MEANS THAT I NEED ONE MORE PIECE OF TAPE. FORGOT ABOUT THAT ONE.
YOU ALSO NEED A LUBRICANT.
WHEN WE PUT THIS DOWN, YOU NEED A WATER SOLUBLE LUBRICANT
THAT YOU'RE GOING TO PUT ON THE TUBE, ABOUT 2 TO 3 INCHES OF THE TUBING.
PLEASE DON'T USE THIS ON MY MANNEQUINS.
YOU CAN HAVE IT FOR A PROP, BUT WHAT WE USE ON MANNEQUINS IS SILICON SPRAY
OR A LIQUID SOAP THAT'S IN THE LITTLE WHITE BOTTLE.
DON'T USE THIS ON HUMAN BEINGS.
IT WILL NOT BE GOOD. THIS IS FOR HUMAN BEINGS.
THIS IS FOR MANNEQUINS.
IF WE USE THIS ON THE MANNEQUINS, IT GETS ALL GUMMED UP.
AND THE SECOND OR THIRD PERSON...IT WON'T GO.
ALRIGHT. I THINK I HAVE ITEMIZED EVERYTHING.
YOU DON'T HAVE TO ITEMIZE YOUR SUPPLIES FOR ME, YOU'LL EITHER HAVE THEM OR YOU WON'T.
SO THE OTHER THING I JUST DON'T WANT TO FORGET IS THAT I WANT TO OFFER ORAL CARE FOR MY CLIENT.
BUT I ALSO MAY WANT TO GIVE HIM THE BASIN IF HE NEEDS TO THROW UP.
SO IT'S, KIND OF, A DOUBLE DO, IF I FEEL LIKE THEY'RE GOING TO RETCH.
ALRIGHT. I HAVE ALL MY SUPPLIES,
MY HANDS, I WASHED THEM BEFORE ALL THIS.
I'M GOING TO IDENTIFY MY CLIENT, AND HE'S A LITTLE SCHIZOPHRENIC.
I NEEDED HIM TO BE CONRAD CURRY THIS MORNING,
OR HE CAN BE SAM SPADE, WHATEVER. SO, WHATEVER YOU NEED HIM TO BE.
AND PROVIDE A PRIVACY.
ALRIGHT, MR. CURRY, I NEED TO PUT A TUBE INTO YOUR STOMACH.
I KNOW THE DOCTOR TALKED TO YOU ABOUT THAT, SINCE YOUR STOMACH IS BLEEDING
AND WE NEED TO GIVE IT A REST AND GET THOSE COFFEE GROUNDS OFF YOUR STOMACH.
SO WHAT WE'RE GOING TO DO IS PASS A TUBE THROUGH YOUR NOSE,
DOWN YOUR THROAT, INTO YOUR STOMACH.
AND THE TRUTH IS, IT'S A LITTLE UNCOMFORTABLE GOING THROUGH YOUR NOSE,
IT'S GOING TO MAKE YOU, KIND OF, SQUINT YOUR EYES
AND IT MAY BURN A LITTLE BIT, IT'S WHAT CLIENTS TELLS ME.
SO, WHAT I'M GOING TO DO IS I'M GOING TO PASS IT
THROUGH YOUR NOSE TO THE BACK OF YOUR THROAT. IT WILL PROBABLY MAKE YOU GAG,
AND RIGHT ABOUT THERE I'M GOING TO STOP AND LET YOU GET RECOMPOSED
BECAUSE IT'S JUST A LITTLE TRAUMATIC AT THAT POINT.
AFTER YOU, KIND OF, GOT YOUR BEARINGS,
THE NEXT THING I WANT TO DO IS, I'M GOING TO HAVE YOU DRINK FOR ME.
AND IF YOU CAN DRINK, AS YOU'RE DRINKING,
I'LL PASS THE REST OF THE TUBE DOWN.
AND WHAT THE DRINKING DOES IS IT CLOSES OFF YOUR...
..TRACHEA. THANK YOU, I WAS JUST HAVING A MOMENT.
CLOSES OFF YOUR TRACHEA AND THEN IT WILL GO RIGHT DOWN THE ESOPHAGUS INTO YOUR STOMACH.
AND THAT'LL HELP SO THAT WE DON'T HAVE IT GO DOWN THE WRONG SPOT FOR YOU.
ALRIGHT. YOU THINK YOU CAN DO THAT? GREAT.
EXPLAIN TO HIM WHAT'S COMING, EXPLAIN WHAT'S HAPPENING.
THE OTHER THING I PROBABLY WILL HAVE YOU DO DURING THIS
IS TO TUCK YOUR CHIN DOWN WHILE YOU'RE DRINKING,
BECAUSE THAT ALSO CLOSES OFF THE TRACHEA
SO IT DOESN'T GO DOWN YOUR AIRWAYS. WE DON'T WANT IT DOWN THERE.
THEN YOU CAN'T BREATHE. THAT WILL BE A PROBLEM.
SO WE WANT IT DOWN THE RIGHT SPOT. OKAY.
I NEED TO DO A COUPLE OF THINGS. I DO WANT TO ASSESS YOU.
I WANT TO LISTEN TO YOUR LUNGS.
AND YOU KNOW WHEN YOU LISTEN TO LUNGS YOU LISTEN TO SIDE TO SIDE...
..TOP TO BOTTOM, SIDES AND BACK.
SIDE TO SIDE, TOP TO BOTTOM, AT LEAST 6 --
WE USUALLY DO 4 TO 6 ON THE FRONT, IT VARIES.
4 -- 6 ON THE BACK, AS IF THERE'S A FRONT MIDDLE AND A BOTTOM.
ALTHOUGH YOU DON'T HAVE MIDDLE LOBES, REMEMBER THAT.
AND DON'T DOCUMENT THAT THE MIDDLE LOBES ARE CLEAR.
HAVE YOU LOOKED AT PICTURES OF HOW THE LOBES GO UP?
IT'S THE BASE LOBE THAT'S ALL THE WAY THROUGH THE BACK OF YOUR LUNGS.
AND ONLY ONE LUNG HAS 3 LOBES.
SO, YOU GOT TO BE CAREFUL ABOUT HOW YOU DOCUMENT THAT.
YOU CAN JUST SAY THE MIDDLE AREA,
BUT IT'S NOT THE MIDDLE LOBE NECESSARILY, THAT'S CLEAR.
SO, BE CAREFUL IN YOUR DOCUMENTATION.
SO I'M LISTENING TO THE LUNGS BECAUSE I WANT TO MAKE SURE THE STATUS
BEFORE THE TUBE GOES IN, IN CASE THERE'S ANY ASPIRATION.
AND FINALLY, I WANT TO ASSESS THE STOMACH AND LISTEN TO BOWEL SOUNDS,
AND SEE HOW THEY'RE DOING WITH THAT.
AND WE'VE ALREADY TALKED ABOUT THAT.
ALWAYS INSPECT BEFORE YOU DO ANY ASSESSMENT.
YOU'RE LOOKING AT COLOR, SYMMETRY, CONTOUR.
AND THEN YOU'RE GOING TO LISTEN RIGHT LOWER QUAD,
GO AROUND CLOCKWISE, ONE MINUTE IN EACH QUAD,
IF YOU DON'T HEAR A SOUND.
UP TO 5 MINUTES BEFORE YOU SAY, NO BOWEL SOUNDS.
ALRIGHT. I WANT TO DO ONE OTHER ASSESSMENT
BEFORE I START MEASURING MY TUBE AND THAT IS,
MR. CURRY, COULD YOU BREATHE IN AND OUT OF YOUR NOSE FOR ME?
AND I WANT TO PLUG ONE NOSTRIL AND SEE HOW THE AIR PASSES.
LISTEN.
AND LISTEN, AND SEE IF I HEAR MORE AIR FROM ONE NOSTRIL OR THE OTHER.
AND I ALSO WANT TO TAKE A LOOK IN THE NOSTRILS
AND MAKE SURE I DON'T DETECT ANY DEVIATED SEPTUM.
ANY CURVATURE OR ANYTHING THAT MIGHT KEEP THIS TUBE FROM PASSING.
AND ASK, "DO YOU HAVE A DEVIATED SEPTUM?
DO YOU HAVE ANY DIFFICULTY BREATHING? HAVE YOU HAD ANY NASAL SURGERIES?
ALRIGHT. WELL, EVERYTHING SEEMS CLEAR.
I'M PROBABLY JUST GOING TO GO OVER HERE ON THE RIGHT HAND SIDE, IF YOU DON'T MIND.
I'M GOING TO PUT THE BED UP A LITTLE BIT.
AND WHAT I WANT TO DO NEXT IS MEASURE
SO THAT I HAVE THE TUBE THE RIGHT LENGTH TO GO INTO THE STOMACH.
- IF THEIR ANXIETY LEVEL'S TOO HIGH, CAN WE GET THEM ANYTHING?
- POSSIBLY. IF THE DOCTOR'S ORDERED SOMETHING AND IF THEY'RE COMBATIVE
AND YOU DON'T THINK THEY'RE GOING TO COOPERATE, YOU REALLY NEED A SECOND PERSON.
BECAUSE THE NATURAL INSTINCT FOR SOMEONE THAT'S CONFUSED
IS TO GRAB, AND THEY GRAB AT YOUR HANDS.
AND IT'S VERY HARD TO SHUT SOMETHING IN WHILE SOMEONE'S GRABBING AT YOU THIS WAY.
SO YOU JUST REALLY NEED SOMEONE TO HELP YOU
HOLD THEIR HANDS IF THEY DON'T COOPERATE.
SO I'VE DONE THEM EVERY WHICH WAY AND WHATEVER WORKS ON THAT.
- DIANE, DO YOU HAVE SOME PROBLEMS WITH QUALITY, I MEAN --
- YES, I'M GOING TO TELL YOU STORIES.
OH, THE SECOND HALF OF THE SEMESTER IS STORIES
BECAUSE WE'RE DOING SOME STUFF. ALRIGHT.
WHAT WE NEED TO DO IS, WE NEED TO MEASURE FOR THE RIGHT LENGTH.
AND WHAT YOU WANT TO DO IS TAKE YOUR TUBE
FROM THE TIP OF THE NOSE TO THE EARLOBE
AND LOOK AND MAKE SURE THAT YOU'RE AT THE END OF THE XIPHOID PROCESS.
OKAY. ONCE YOU GET THERE, THEN YOU JUST TAKE A LITTLE PIECE OF TAPE
AND MARK IT.
YOU COULD LOOK AT THE LITTLE BLACK LINES. BUT ONCE YOU'VE PASSED IT THROUGH,
YOU CAN'T REMEMBER IF YOU'RE AT THE FIRST OR THE SECOND LINE, SO THAT'S A LITTLE RISKY,
WHEN YOU'RE DOING IT BY THE LINE COUNT.
THE OTHER METHOD THAT YOU COULD CONSIDER
IS THEY SAY THAT IF YOU MEASURE 50 CENTIMETERS ON YOUR TUBE
AND THEN DO THIS MEASUREMENT,
THAT THE MEASUREMENT BETWEEN YOUR MEASUREMENT AND THE 50 CENTIMETERS
SMACK IN THE MIDDLE IS THE OTHER MEASUREMENT.
DOES THAT MAKE SENSE? IT'S A LITTLE WORDY.
BUT IT MAKES A LITTLE BIT LONGER LENGTH, JUST TO MAKE SURE, YOU'RE IN THE STOMACH.
SO 50 CENTIMETERS IS, AS LONG AS YOU WOULD WANT IT TO BE.
YOU CAN DO THE TRADITIONAL MEASURE WHICH IS EAR, NOSE.
IT DOESN'T REALLY MATTER WHICH DIRECTION, XIPHOID PROCESS
AND THEN FROM THE 50 CENTIMETER PART AND THE NOSE PART, IT WOULD BE RIGHT IN THE MIDDLE.
SO IT WOULD BE ON THE OTHER SIDE OF MY TAPE, THEORETICALLY.
OKAY.
I THINK IN YOUR PAPER, ALL I PUT WAS JUST TO DO THIS ONE.
OKAY. AND THEN MARK IT.
YOU NEED A MARK SO THAT YOU KNOW HOW FAR TO GO.
OKAY.
MY TUBE IS READY. I WANT TO PUT A LITTLE BARRIER...
..HERE.
I WANT TO HAVE MY PH PAPER READY TO GO.
WHAT PH ARE YOU LOOKING FOR WHEN YOU MAKE YOUR ASPIRATE?
- 3 OR LESS.
- 3 IS A GOOD ONE. WHAT'S SO GREAT ABOUT 3?
BECAUSE IT'S BELOW 6, THAT'S WHAT'S GOOD ABOUT IT.
[LAUGHTER]
ALRIGHT, SO STOMACH CONTENTS ARE USUALLY 6 AND BELOW.
INTERESTINGLY, THEY SAY, ANYTHING ABOVE 3
IS MORE ACIDIC AND IT CAN CAUSE ACTUALLY ASPIRATION PNEUMONIA.
IT PUTS THEM AT A GREATER RISK, THE HIGHER THE NUMBER IS.
SO, YOU LIKE NUMBERS FOUR AND BELOW FOR YOUR CLIENT
AND THAT'S USUALLY A PRETTY SAFE INDICATOR
THAT YOU'RE IN THE STOMACH RELATED TO PH.
NUMBERS BETWEEN 6 AND 7.5 USUALLY INDICATE LUNGS.
AND 7.5 AND ABOVE IS BOWELS.
SO, YOU NEED TO KNOW FOR SURE WHAT KIND OF TUBE YOU HAVE.
DO YOU HAVE A TUBE THAT'S IN THE STOMACH OR DO YOU HAVE ONE OF THOSE FEEDING TUBES
THAT'S IN THE INTESTINES, BECAUSE YOU'RE NOT GOING TO PANIC AND TAKE THE THING
OR PULL ON IT IF YOU GET A 7.5, IF IT'S IN A DOBHOFF TUBE,
THAT'S WEIGHTED DOWN IN THE INTESTINES.
SO, MAKE SURE YOU KNOW WHERE YOU'RE HEADING.
WORK HIS STOMACH AND WE NEED A FOUR.
MAKE SURE YOU GOT PAPER THAT'S THE RIGHT PARAMETERS.
SO YOU NEED PAPER THAT'S ONE TO 12 SO THAT YOU CAN GET THE RIGHT PH.
OKAY.
GLOVES AT THIS POINT.
AND WE'RE PUTTING IT IN.
OKAY, ON A HUMAN BEING,
BEFORE I PUT IT IN, I WOULD TAKE AND LUBRICATE WITH K-Y JELLY, 3 INCHES.
ON A MANNEQUIN, I'M GOING TO GET SOME SILICON SPRAY.
AND OH, THIS STUFF IS EVER SO SLIPPERY. I'M GOING TO GIVE IT A SQUIRT.
AND IF YOU'LL GIVE IT A SQUIRT IN THE NOSE, IT WILL REALLY SLIDE IN GOOD.
OKAY.
- IS THAT THE GOOD NOSTRIL? - I BELIEVE IT IS.
OKAY.
NOW, INTERESTINGLY, ON A PERSON,
YOU HAVE THIS VISUAL. I KNOW YOU'RE VISUALS LIKE ME.
AND THE NOSE LOOKS LIKE IT'S GOING UP
AND SO YOU HAVE THIS INCLINATION TO WANT TO GO UP.
BUT YOU DON'T GO UP, YOU GO DOWN.
AND YOU FOLLOW THE BASE PATH OF MY --
I DON'T HAVE MY LITTLE HEAD ANYMORE.
BUT DID YOU NOTICE HOW THE NARIES GO STRAIGHT?
CHRISTINE, I WANT YOU TO JUST HOLD UP THE NOSE.
WE'LL PUT YOU ON CAMERA HERE FOR JUST A BRIEF MOMENT, NICE [INDISTINCT].
SEE HOW THE -- FROM THE NARIES, HOW IT GOES STRAIGHT ACROSS.
IF YOU GO UP, YOU GO UP INTO THE TERMINATES.
IT'S STRAIGHT ACROSS.
AND YOU'RE ACTUALLY, KIND OF, GOING TOWARDS THE EAR.
OKAY, SO DOWN AND TOWARDS THE EAR. SO, MAKE SURE THE CURVE IS DOWN.
ALRIGHT. HERE WE GO, MR. CURRY, THIS IS GOING TO BE A LITTLE UNCOMFORTABLE,
BUT IF YOU'LL JUST LET THIS GO IN, AND I'M GOING TO PASS AND PASS
TILL IT GETS TO THE BACK OF YOUR THROAT.
[CLICKING]
OKAY, AND STOP. PULL BACK A LITTLE SO THEY'RE NOT GAGGING AND LET THEM GET COMPOSED.
IT'S NOT COMFORTABLE.
CAN YOU IMAGINE SOMETHING UP YOUR NOSE? I MEAN, URGH!
ALRIGHT. AT THIS POINT I WANT TO TAKE MY FLASHLIGHT AND LOOK.
AND SURE ENOUGH, THAT TUBE IS IN THE BACK THERE. IT'S BEAUTIFUL.
I'M GOING TO GIVE MY CLIENT THIS CUP...
..WHICH THEY WOULD HOLD AND BE READY TO DRINK FROM.
AND I'M GOING TO TELL MY CLIENT, MR. CURRY, IF YOU COULD PUT YOUR CHIN TO YOUR CHEST,
THAT WILL CLOSE OFF THAT AIRWAY. AND THEN I'M GOING TO HAVE YOU DRINK HERE ON JUST A SECOND,
IF YOU CAN JUST HOLD THE CUP." BUT I WANT TO DO ONE OTHER LITTLE THING.
REMEMBER, MY TUBE IS GOING LIKE THIS?
IT CAN COME OUT THE MOUTH, IF I KEEP THAT CURVE GOING.
IF YOU'LL TAKE YOUR TUBE AND GIVE IT A LITTLE HALF TWIST,
NOW THE CURVE IS GOING THE OTHER WAY
AND THEN IT WILL GO TOWARDS THE BACK OF THE THROAT
AND YOU WON'T KEEP SENDING IT DOWN THAT AIRWAY OR OUT THE MOUTH.
A LITTLE TRICK TO REMEMBER, NOT IN THE BOOK. IT'LL HELP YOU.
OKAY, SO I'M GOING TO GIVE A LITTLE TWIST, CHIN TO CHEST.
AND, "ALRIGHT, MR. CURRY, IF YOU COULD START DRINKING,
I'M GOING TO PASS THIS THE REST OF THE WAY DOWN."
AND HE STARTS DRINKING, DRINKING, DRINKING, DRINKING,
DRINKING, DRINKING AND I JUST KEEP PUTTING IT ON DOWN TILL I REACH MY TAPE.
AND I SAY, "OKAY, THAT'S GOOD, THAT'S ENOUGH,"
ALRIGHT. NOW, AT THIS POINT,
YOU COULD TAKE A LITTLE PIECE OF TAPE,
IF YOU FEEL LIKE YOU'RE GOING TO GET SOME SLIPPAGE.
IT'S GOING JUST A LITTLE BIT FURTHER.
AND JUST KIND OF HAVE IT JUST STICK HERE FOR A SECOND SO YOU CHECK PLACEMENT.
RIGHT? BECAUSE YOU NEED TO KNOW IF IT'S IN THE RIGHT PLACE
BEFORE YOU GO VIGOROUSLY TAPING IT ALL UP.
SO, WHAT I WANT TO DO HERE IS
ASPIRATE AND GET SOME RESIDUAL CONTENTS
AND I ALSO WANT TO GET ENOUGH FOR PH.
CHECK THE PH.
AND SEE WHAT IT IS BEFORE I GO SHOVING THIS BACK IN.
YOU WANT TO MAKE SURE IT'S 4 BELOW.
THEN I CAN RETURN IT OR LEAVE IT OUT.
IT JUST DEPENDS ON WHAT YOU'RE DOING, I MEAN, AT THAT POINT.
I'M GOING TO CONNECT IT RIGHT NOW.
AND THEN ONCE I'VE VERIFIED PLACEMENT,
I WANT TO ASK YOU A COUPLE OF OTHER THINGS. CAN YOU SPEAK?
YOU KNOW, I CHECKED THE BACK OF THE THROAT.
IF THEY CAN TALK, THAT'S USUALLY A PRETTY GOOD INDICATOR YOU'RE NOT DOWN THE TRACHEA
SO THEY CAN SPEAK. I'VE SEEN THE TUBING IN THE BACK OF THE THROAT.
I OPEN THEIR MOUTH, AND MAKE SURE IT'S NOT ALL COILED UP BACK THERE.
I HAD THE FUNNIEST THING. THIS CONFUSED SWEET, LITTLE OLD LADY,
I WAS PUTTING THE TUBE DOWN, I CAN'T REMEMBER WHAT IT WAS FOR.
BUT SHE JUST SMILED AT ME, AND I SHOVED THE LITTLE TUBE DOWN AND SHE JUST SMILED
AND I SAID, "CAN YOU TALK?" AND SHE WENT...AND THEN SHE WENT...
THE WHOLE THING COILED UP ON HER TONGUE AND IT HAD COME OUT.
AND I WAS LIKE, "OH, SHOOT."
YOU KNOW, SO I HAD TO PULL IT OUT AND THEN START OVER BECAUSE THAT WAS NO GOOD.
AND SHE DIDN'T CARE WHAT I DID TO HER REALLY.
BUT YOU JUST DON'T ALWAYS KNOW SOMETIMES.
SO THAT'S WHEN THAT LITTLE TWISTY THING WILL HELP.
ALRIGHT. SO MY CLIENT CAN SPEAK, PLACEMENT'S GOOD,
YOU CAN TAKE THIS OLD MARKER TAPE OFF...
..SO THAT YOU DON'T HAVE A BUNCH OF STUFF ON THERE.
AND THEN WHAT I DID WAS I PUT THE WHOLE PIECE OF TAPE ON ONE SIDE,
ON THE NOSE AND THEN TAKE YOUR SPLIT AND WRAP IT AROUND THE TUBE ONE WAY.
AND THEN TAKE YOUR OTHER AND THEN WRAP IT AROUND THE TUBE THE OTHER WAY.
AND THAT WILL STABILIZE THAT ON THE NOSE.
AND THEN IF YOU FEEL LIKE YOU NEED ONE MORE PIECE ACROSS THE BRIDGE OF THE NOSE,
BECAUSE THEY DO TEND TO SLIDE OFF,
YOU COULD PUT ONE MORE ACROSS THE BRIDGE LIKE THAT.
THOSE MANUFACTURED NG TUBES THAT I'VE USED,
IT'S A LITTLE PLASTIC BAR WITH THIS RING.
AND I ALMOST ALWAYS HAVE STABILIZED THOSE
WITH ANOTHER PIECE ACROSS THE BRIDGE BECAUSE THEY DO TEND TO SLIDE OFF
AND THEY DON'T STAY STABLE.
ALRIGHT.
HE'S DOING FINE HERE.
I WANT TO MEASURE THE LENGTH OF TUBING
THAT IS COMING OUT OF HIS NOSE.
AND SO, I'M GOING TO MEASURE FROM HIS NOST-- HIS NOSE HERE TO THE END.
AND I'M GOING TO SAY, TO THE END OF THE WHITE PIECE WHICH IS 29 INCHES.
SO THAT THE NEXT PERSON KNOWS IF THERE'S ANY QUESTION AS TO PLACEMENT,
THEY CAN MEASURE THE LENGTH, LOOK AT THE BACK OF THE THROAT.
I MEAN, WHAT IF THEY'RE NOT GETTING ASPIRATE OUT,
HOW DO YOU KNOW IT'S IN THE RIGHT PLACE?
I'M ALSO GOING TO -- ONCE I'M ALL DONE HAVE HIM GET A CHEST X-RAY,
BECAUSE THAT'S REALLY THE ONLY WAY THAT YOU CAN ABSOLUTELY KNOW
THAT YOU'RE IN THE RIGHT PLACE, IS CHEST X-RAY.
SO WE'LL GET THAT IN A BIT.
LET ME GO AHEAD AND PLUG THIS FOR NOW.
AND I WANT TO PUT ON -- WASTED ONE OF MY PIECES OF TAPE.
SO, I'M GOING TO PUT ON ONE OTHER PIECE OF TAPE HERE.
AND YOU WANT TO JUST CURVE THIS A LITTLE BIT,
PUT A PIECE OF TAPE ON THE TUBING AND DOUBLE BACK IT.
AFTER WE GET THIS SILICON GOING, EVERYTHING IS SO SLIPPERY. NOTHING STICKS.
THAT'S GREAT.
AND THEN GET YOUR SAFETY PIN, BECAUSE YOU DON'T WANT IT HANGLING IN --
DANGLING LIKE THAT BECAUSE IT WILL PULL ITSELF OUT OF PLACE.
SO, PIN THE TAPE, NOT THE TUBING TO THE GOWN
SO THAT IT'S STABLE HERE AND NOT CAUSING TRAUMA ON THE NOSE.
OKAY, GET MY CHEST X-RAY. GO AHEAD AND LEAVE THEM UP.
IF THEY NEEDED TO HAVE HIM SUCTIONED, YOU WOULD PUT HIM TO SUCTION.
AND THAT'S IT. HE LOOKS WONDERFUL.
HOW ARE YOU DOING? IT'S NOT COMFORTABLE, HUH?
ALRIGHT, WELL, WHEN YOU HAVE THAT TUBE IN,
WE WANT TO MAKE SURE TO GIVE YOU GOOD ORAL CARE.
SO WE'LL LEAVE YOU SOME TOOTHETTES SO THAT YOU CAN FRESHEN UP YOUR MOUTH.
AND THEN IT WOULD BE GOOD IF YOU AT LEAST BRUSH YOUR TEETH MORNING AND NIGHT,
AND EVEN AFTERNOON WOULDN'T HURT ANYTHING.
SO, GOOD ORAL HYGIENE. MAKE SURE YOUR CLIENT TURNS EVERY 2 HOURS.
JUST BECAUSE THEY HAVE A TUBE IN DOESN'T MEAN THEY HAVE TO SIT LIKE THIS FOREVER.
THEY NEED TO MOVE AROUND. MOST OF THE TIME, YOU DO WANT THEIR HEAD UP A LITTLE BIT
BECAUSE IT PREVENTS ASPIRATION, THAT'S WHY.
SO, I WOULD WASH MY HAND, CLEAN UP MY MESS.
WASH MY HANDS. AND DOCUMENT THE SIZE OF TUBE I USED,
WHICH NOSTRIL IT WAS IN,
HOW THEY TOLERATED IT AND WHAT KIND OF CONTENTS I GOT BACK,
HOW I VERIFIED FOR PLACEMENT.
SO YOU WANT TO NOTE THE CHEST X-RAY
AND I'D WANT TO NOTE THAT THE CLIENT COULD SPEAK,
THAT THE PH WAS WHATEVER THE PH WAS.
TUBE VISUALIZED IN THE BACK OF THE THROAT AND UP TO SUCTION.
AND I GOT SO MUCH COFFEE GROUNDS BACK, POOR SOUL.
OKAY. LET'S TALK ABOUT SOME STORIES HERE.
THE CLIENT COMES IN AND THEY HAVE A GI BLEED.
A GI BLEED COME IN ONE DAY, AND I PUT QUITE A FEW TUBES DOWN,
SO I REALLY WASN'T ANTICIPATING MUCH OF A DISASTER.
AND GOT MY PARAPHERNALIA TOGETHER, AND I NOTICED THAT HIS STOMACH WAS REALLY DISTENDED.
SO HE'D BEEN BLEEDING FOR A WHILE AND HE WASN'T PASSING WELL THROUGH THE BOWELS
AND HE JUST HAD COFFEE GROUNDS, HE HAD BEEN THROWING UP AT HOME.
AND HE REALLY WAS A MISERABLE, MISERABLE MAN.
SO I HAD ALL MY SUPPLIES TOGETHER AND I STARTED PUTTING THE TUBE DOWN
AND IT WAS JUST LIKE TAKING THE FINGER OUT OF THE DYKE.
AS SOON AS I HIT HIS STOMACH CONTENTS, HE JUST RETCHED.
AND THIS TUBING, WHEN IT HIT THE FLUID, WHOOSH, WHOOSH, WHOOSH OF COFFEE GROUND.
I HAD COFFEE GROUNDS EVERYWHERE, I HAD BLOOD EVERYWHERE.
HE WAS STILL -- I HAD BODY FLUIDS EVERYWHERE
I HADN'T PLUGGED MY END.
SO I WASN'T READY FOR THAT, AT ALL.
SO I MIGHT SUGGEST THAT IF YOU HAVE SOME DISTENSION
THAT'S PRETTY VISIBLE AND THEY'RE BLEEDING AND YOU KNOW THERE'S STUFF ON THE STOMACH
AND YOU'RE PUTTING A TUBE IN FOR RELIEF, YOU MIGHT WANT TO PLUG THIS.
AND YOU MIGHT WANT TO PUT A COUPLE OF CHUX DOWN
INSTEAD OF YOUR ONE LITTLE TOKEN CHUX, AND THIS,
WHAT A JOKE, HE NEEDED A BOWL.
SO, BE PREPARED. I JUST WASN'T. AND IT WAS HUGE, IT WAS A MESS.
AND, YOU KNOW, IT'S NOT LIFE OR DEATH, HE NEEDED A TUBE, HE NEEDED THE RELIEF.
OH, I HAD A HUGE MESS ON MY HANDS.
HE FELT REALLY BAD. BUT WHAT DO YOU DO? IT WAS JUST A MESS.
I TOLD YOU ABOUT THE TUBE OUT THE MOUTH.
ANOTHER TRICK TO PUTTING TUBES DOWN
IS SOMETIMES ON THE TUBES THERE'S --
THEY NEED TO BE A LITTLE STIFFER. PART OF THE PROBLEM IS THEY'RE SOFT,
AND THAT'S WHY THEY KEEP COMING OUT THE MOUTH.
SO IF YOU'LL TAKE YOUR TUBE AND PUT IT ON ICE FOR A FEW MINUTES,
THAT'LL STIFFEN IT UP A LITTLE BIT
AND YOU'LL HAVE BETTER LUCK GETTING IT TO GO STRAIGHT
THAN IF YOU JUST PUT IT IN, ROOM TEMP.
I DON'T HAVE ANY MORE STORIES. I DON'T REMEMBER ANY MORE STORIES TO OFFER.
ONLY THE BASIC ONES I THINK ON NGS.
COMBATIVE CLIENTS, WHEN THEY'RE CONFUSED, THEY SWAT AT YOU, SO YOU NEED SOMEONE TO HELP YOU.
AND IF YOU CAN JUST TALK THROUGH WITH PEOPLE, WHAT THEY'RE SUPPOSED TO DO,
MOST OF THE TIME, THEY'LL COOPERATE PRETTY WELL.
THE MAIN THING IS IT'S PRETTY UNCOMFORTABLE AS IT PASSES
THROUGH THE NARIES PART IN THE BACK OF THE NASAL PHARYNX, IT'S A LITTLE UNCOMFORTABLE.
- AT CLINICAL YESTERDAY WE WERE REVIEWING,
MY PATIENT'S CHARTS AND I NOTICED, SHE'D BEEN HERE FOR 12 DAYS,
BUT ABOUT THE SECOND DAY SHE PULLED OUT HER TUBE, IS THAT RELATIVELY COMMON?
BECAUSE WE WERE TALKING ABOUT A COUPLE OF CASES AND THEY WERE --
- COMMON IS RELATIVE. IT DEPENDS ON HOW CONFUSED THEY ARE.
MY CONFUSED CLIENTS, I'VE HAD WITH FEEDING TUBES PULL THEM OUT ALL THE TIME.
AND THAT'S WHY THEY'RE NOT A GOOD TREATMENT
FOR CONFUSED PEOPLE THAT NEED FEEDING TUBES
BECAUSE THEY PUT THEM ON A HIGH RISK FOR ASPIRATION.
THAT'S WHY YOUR G TUBES ARE BETTER.
IF THEY'RE CONFUSED AND YOU STILL NEED IT,
BECAUSE YOU'RE DOING THE LAVAGE,
YOU'RE PULLING OFF ON THE DECOMPRESSION, BOY, YOU'RE IN A PICKLE.
THAT'S WHEN RESTRAINTS OR SEDATION OR SOMETHING,
FAMILY MEMBERS THERE ALL THE TIME TO HELP YOU.
AND THEN WE HAVE TO REPLACE.
YOU KNOW, THERE COMES A POINT OF YOU CALLING THE DOCTOR AND SAYING,
"THIS IS NOT WORKING. I PUT IT IN, THEY PULL IT OUT. THIS IS TOO TRAUMATIC."
SO, ONCE OR TWICE, I MEAN WE'LL PUT THEM BACK IN.
BUT IF THIS IS LIKE EVERY 8 HOURS,
THIS IS OUT OF CONTROL, NOT WORKING.
SO, I DON'T KNOW, COMMON. BUT IT HAPPENS A LOT. AND WE REPLACE THEM.
THEY CAN GET STUCK ON THINGS AND GET PULLED PUT OR DISPLACED.
DO YOU HAVE A QUESTION OVER HERE?
IF YOU DON'T GET FLUID BACK TO CHECK PH, THAT'S, KIND OF, A CHALLENGE, RIGHT?
WHAT DO YOU DO IF THERE'S NO FLUID?
SO YOU WANT TO CHECK ALL OF YOUR INDICATORS
AND MAKE SURE THAT THE TUBE IS THE SAME LENGTH,
MAKE SURE THAT YOU SEE TUBING IN THE BACK,
MAKE SURE THEY CAN SPEAK. AND IF YOU JUST DON'T GET ANYTHING BACK,
I MIGHT HAVE THEM ROTATE POSITIONS, YOU KNOW, AND SEE IF I CAN CATCH SOMETHING
IF THEY ARE LAYING ON ONE SIDE AS OPPOSED TO ANOTHER.
PROBABLY LAST BUT NOT LEAST, I'D TRY THE AIR IN THE STOMACH
JUST TO SEE IF I HEARD, EVEN THOUGH IT'S NOT RECOMMENDED.
BUT ALL MY OTHER SIGNS ARE INTACT.
THEN I WOULD GO AHEAD WITH MY FEEDING OR
MY ASPIRATION, AS LONG AS EVERYTHING ELSE IS EXACTLY THE SAME.
LENGTH OUT HERE, TUBE DOWN THE BACK, SPEAKING,
NO VISIBLE CHANGE, I JUST AM NOT GETTING FLUID BACK.
MOST OF THE TIME YOU WILL, BUT THERE IS THAT RARE INSTANCE, IT'S, LIKE, WHAT DO YOU DO?
PANIC? TAKE THE TUBE OUT? CALL THE DOCTOR?
THAT'S JUST NOT WHAT YOU DO.
YOU'RE GOING TO CHECK EVERYTHING AND THEN PURSUE IT.
OKAY. THEY HAVE A NEW TREATMENT. I GAVE YOU A LITTLE PARAGRAPH.
THAT'S I WANT YOU TO LOOK AT, IN OF YOUR ARTICLES ON CAPNOMETRY.
THEY FOUND THAT WITH CAPNOMETRY THAT THEY CAN READ
THE CARBON DIOXIDE ON RESPIRATORS
TO SEE HOW THE AIR EXCHANGES.
AND THEY FOUND THAT IF THEY HOOKED THE CAPNOMETRY READER TO THE END OF THE TUBE,
IF IT READ IN CERTAIN PARAMETERS,
THEN IT WAS NOT IN THE LUNG, BUT IF YOU GOT A CERTAIN READING
WITH THE CARBON DIOXIDE, IT WAS IN THE LUNG.
AND IT WAS 100% CORRECT ON EVERYONE THAT THEY CHECKED.
SO, THEY WERE RESEARCHING AND IN THE PROCESS OF DECIDING
IF THEY WOULD RATHER USE THAT THAN X-RAY.
BECAUSE, THE X-RAY ISN'T THAT SAFE TO BE USING ON CLIENTS ALL THE TIME.
AND IF IT'S 100% EFFECTIVE
WELL, THEN WE GOT A GREAT TOOL AT BEDSIDE
TO USE INSTEAD OF ALL THIS PH, WE CAN'T GET ANYONE TO USE ANYWAYS.
YOU KNOW, AND MESSING IN THE BODY FLUIDS.
JUST OPEN THE END, CHECK FOR EXCHANGE AND YOU'RE GOOD TO GO.
SO, ANYWAYS INTERESTING LITTLE ARTICLE AND I THOUGHT THAT WOULD BE HELPFUL FOR YOU.
I ALSO PUT IN A WONDERFUL ARTICLE THAT HAS PICTURES
AND DESCRIPTIONS OF ALL THE DIFFERENT KINDS OF TUBES
SO THAT YOU CAN REVIEW WHAT THEY'RE FOR,
WHAT THEY LOOK LIKE AND HOW DO I KNOW WHAT TO PICK
WHEN IT COMES MY TURN TO PUT AN NG IN FOR SUCTION.
YOU'RE GOING TO PICK THE SALEM SUMP TUBE 14 TO 6,
BUT IT GIVES YOU SOME OF THOSE PARAMETERS TO HELP YOU DECIDE WHAT YOU NEED.
ALRIGHT. AFTER YOU PUT YOUR TUBE IN, THEN YOU GOT TO BC YOUR TUBES.
SO WE CHECKED OUR DOCTOR'S ORDERS.
AND THE DOCTOR SAID, "BC THE TUBE."
WE'RE GOING TO GATHER UP OUR EQUIPMENT.
THE EQUIPMENT GATHERING IS MUCH SIMPLER ON THIS ROUND.
YOU NEED A PAPER TOWEL AND SOMETHING FOR ORAL HYGIENE AND YOUR SYRINGE.
SO THE CHUX WOULD PROBABLY GET PUT ACROSS THE CHEST.
WASHED MY HANDS AND IDENTIFIED MY CLIENT, CONRAD CURRY AND PROVIDE HIM PRIVACY.
ALRIGHT, MR. CURRY, YOU'RE DOING SO GOOD. WE'RE GOING TO TAKE THAT TUBE OUT.
IT'S A LITTLE UNCOMFORTABLE COMING OUT COS IT'S GOT TO COME OUT THE SAME WAY IT WENT IN,
BUT WE'RE NOT FOCUSED SO MUCH, IT JUST SLIDES OUT.
WHAT PATIENTS TELL ME IS THAT BECAUSE THE TUBE HAS BEEN SITTING IN THE STOMACH
THAT SOME OF THAT BILE, THEY CAN, KIND OF, TASTE IT WHEN IT GETS UP TO THE NASAL,
TO THE BACK OF YOUR THROAT THROUGH THE NOSE AREA.
SO, THERE'S KIND OF A BITTER TASTE, SO WE'LL GIVE YOU SOME GOOD ORAL CARE
AND SEE IF WE CAN GET THAT TAKEN CARE OF.
AND A LITTLE BIT OF BURNING, JUST BECAUSE IT'S PASSING THROUGH THE NOSE.
SO. BUT IT'S JUST A QUICK PULL OUT AND IT'S DONE.
SO, WHAT I WANT TO DO HERE IS...
..FIRST, I'M GOING TO JUST PUT SOME AIR IN THE TUBE.
EVERYTHING LOOKS FINE, BUT WHAT I'D LIKE TO DO
IS I'D LIKE TO CLEAN EVERYTHING OUT OF THE TUBE.
REMEMBER WHEN YOU WERE EMPTYING YOU IV TUBING,
AND THERE WAS FLUID IN IT, BUT YOU NEEDED TO GET ALL THE FLUID OUT.
AND THE HIGHER YOU HOLD IT, THE FLUID LEVEL DROPS,
THE HIGHER YOU HOLD. WELL, THE SAME THING.
IT SITS IN THE STOMACH, THE TUBE AND IT MAY HAVE, KIND OF, LIKE A STRAW DOES,
THAT LITTLE BIT OF FLUID THAT'S SITTING IN THE BASE OF THE TUBE.
IF YOU DON'T GET THAT FLUID OUT, YOU GET DRAG.
AND AS YOU PULL THE TUBE UP, THEN THAT FLUID STARTS COMING OUT OF THE TUBE.
AND SO, AGAIN, YOU HAVE RISK OF ASPIRATION
AND THEN GETTING BILE AND STOMACH CONTENTS IN THE THROAT AREA.
SO, WE WANT TO CLEAR THAT OUT.
SO YOU JUST GO AHEAD AND PUT IN 20 TO 30 CC'S OF AIR, CLEAR YOUR TUBING,
AND THEN LEAVE THE END OF THE TUBING PLUGGED.
IF THE END OF THE TUBING IS PLUGGED,
YOU WON'T HAVE THAT EXCHANGE OF FLUID, IF THERE IS A LITTLE BIT OF FLUID.
BUT WE CAN'T HELP WITH WHAT'S ON THE OUTSIDE. YOU KNOW, IT'S BEEN SITTING IN THE STOMACH
SO IT'S STILL GOING TO BE NOT PERFECT, BUT THAT WILL HELP.
ALRIGHT. MR. CURRY, THERE'S ONE THING THAT I NEED FOR YOU TO DO.
I'M JUST GOING TO TAPE IN THIS HERE FOR YOU.
IS I'M GOING TO ASK YOU TO HOLD YOUR BREATH WHILE I PULL THE TUBE OUT,
AND THAT WILL KEEP THAT BILE FROM GOING INTO YOUR AIRWAY.
SO, IF YOU COULD JUST HOLD YOUR BREATH FOR A SECOND, NOT VERY LONG,
THAT WILL BE HELPFUL.
AND ALL I'M GOING TO DO HERE IS PUT A PAPER TOWEL HERE
SO THAT I CAN CATCH THE TUBE WHEN IT COMES OUT.
SO IF YOU COULD TAKE A GOOD DEEP BREATH AND HOLD IT.
PULL, PULL, PULL, PULL. CATCH THE -- AND OKAY,
YOU CAN BREATHE. AND ENCASE IT --
THESE ARE AWFUL.
AND THEN YOU CAN PUT THE GLOVES ON AGAIN TO GIVE ORAL CARE AND GIVE NASAL CARE.
THAT'S THE OTHER THING, I DON'T REMEMBER IF IT'S ON YOUR SHEET OR NOT,
BUT WHEN THE TUBE WAS IN, YOU NEED TO CHECK THEIR NOSE EVERY 4 HOURS,
AND MAKE SURE YOU CLEAN AROUND THE NARIES
AND CHECK IT FOR ANY KIND OF PRESSURE ULCERATION.
ALRIGHT, HERE YOU GO, AND HERE'S THE KLEENEX.
YOU NEED TO BLOW YOUR NOSE.
AND THEN ORAL CARE, CLEAN THE MOUTH.
AND THEN WASH YOUR -- CLEAN UP YOUR SUPPLIES.
WASH YOUR HANDS AND DOCUMENT.
AND THEN YOU WANT TO BE OBSERVING YOUR CLIENT.
WHAT WOULD YOU BE OBSERVING YOUR CLIENT FOR?
- DISTENSION. - DISTENSION, UH-HUH.
WATCHING POSSIBLE ASPIRATION.
BUT DISTENSION, ARE THEY TOLERATING NOT HAVING THE TUBE ANY MORE TO SUCTION?
SO, WATCHING THEIR BOWELS,
MAKING SURE THAT THEY'RE PASSING FLUIDS.
USUALLY, YOU START THEM OFF ON ICE CHIPS
AND THEN CLEAR LIQUIDS AND MOVE THEM ADVANCE AS TOLERATED AS BOWEL SOUNDS GET ACTIVE
AND THEY'RE ABLE TO TOLERATE THEIR FOODS.
ALRIGHT. ONE OTHER STORY SCENARIO WE NEED TO CONSIDER,
AND THAT IS WHEN THE TUBE IS IN,
YOU HAVE A CLIENT THAT HAS AN NG TUBE IN,
AND THAT'S FOR DECOMPRESSION.
RIGHT? DECOMPRESSION BEING...
- AIR.
- GET THE AIR AND THE BODY FLUIDS OFF THE STOMACH
SO THE BOWELS CAN TAKE A REST AND IT SHOULD RELIEVE NAUSEA.
RIGHT? IF YOU DON'T HAVE ANYTHING IN YOUR STOMACH, WHAT'S THERE TO THROW UP?
IT'S NOT EVEN A DRY HEAVE.
YOU SHOULD RESOLVE NAUSEA AND VOMITING WITH AN NG TUBE,
BECAUSE IT'S TAKING OFF STOMACH CONTENTS.
ALRIGHT. YOUR CLIENT HAS BEEN HAVING THEIR NG IN,
AND THEY'VE BEEN GETTING, OH, I DON'T KNOW,
ABOUT 400 CC'S OFF A SHIFT OR 600 CC'S OFF PER SHIFT.
AND YOU COME IN AND YOU LOOK AT THE BOTTLE AND THERE'S A COUPLE OF 100 IN THERE.
AND NOW YOUR CLIENT IS COMPLAINING ABOUT NAUSEA.
WHAT'S THE PROBLEM?
- IT'S NOT...VACUUMING IT. - IT'S NOT VACUUMING IT.
IT'S NOT VACUUMING IT OUT, EXACTLY.
THEY GOT A BLOCKAGE SOMEWHERE.
YOU NEED TO, AT THAT POINT --
GLOVES, GET YOUR LITTLE SYRINGE.
AND TWO WAYS. YOU CAN DO IT WITH AIR OR YOU CAN DO IT WITH SALINE.
GET SOME SALINE, COME DISCONNECT
AND THEN, WHOOSH, RINSE.
IRRIGATE THAT THING AND SEE IF THAT'S BLOCKED,
IF THAT'S WHAT THE TROUBLE IS.
AND THEN, WHOA, ALL OF A SUDDEN, FLUID STARTS COMING THROUGH.
AND YOU GO, "OH YEAH, BLOCKED."
OKAY. SO, COMPLAINTS OF NAUSEA, COMPLAINTS --
CHANGES IN VOLUME USUALLY MEAN BLOCK TOO.
YOU NEED TO IRRIGATE, AIR, SALINE,
WHATEVER IS APPROPRIATE FOR YOUR CLIENT. ALRIGHT.
- WE WERE DOING IT VERY PRECAUTIONARY,
LIKE, EVERY 2 HOURS ANYWAYS, JUST TO DO IT.
- JUST TO MAKE SURE? - YEAH.
- I HAD A CLIENT THAT I DID THAT ON AND HERE IS STORY NUMBER 800. OKAY.
THEY HAVE A SALEM SUMP TUBE.
ALRIGHT.
SO THE SALEM SUMP IS DOWN INTO YOUR CLIENT.
AND I WALK IN THE ROOM.
AND THERE' -- IT'S CONNECTED TO SUCTION, SO THIS IS OFF.
AND I WALK INTO THE ROOM AND THERE'S BILE IN A BIG PUDDLE ON THE BED.
AND IT'S COMING OUT THIS.
WHAT'S THE PROBLEM?
- THE OTHER SIDE'S STUCK.
- UH-HUH. I GOT BLOCKAGE AGAIN.
THIS SIDE'S BLOCKED
AND SO MY AIR VENT'S NOW TURNED INTO MY BILE VENT
AND I GOT A BIG MESS.
SO YOU CAN CLEAR THIS VENT WITH AIR AND GET THE BILE OUT OF THERE.
IF THAT DOESN'T HELP YOU, ONE IOTA. GET THE BILE OUT.
BUT THEN THIS TUBE NEEDS TO BE DISCONNECTED AND IRRIGATED
SO THAT YOU CAN CLEAR THE BLOCKAGE
AND MAKE SURE THAT YOU GOT FLUIDS COMING OUT HERE, AIR COMING OUT HERE.
SO IF YOUR EQUIPMENT'S NOT WORKING RIGHT,
DON'T JUST GO, "OH, WHAT A MESS."
YOU GOT A PROBLEM. IT'S NOT SUPPOSED TO DO THAT
AND IT'S USUALLY RELATED TO BLOCKAGE.
OKAY, I THINK THAT'S A LOT FOR A TUBE.
OKAY.
I WANT TO SHOW YOU A LITTLE SEVEN-MINUTE VIDEO
OF THE BABY GETTING AN OG FEEDING, AN OROGASTRIC FEEDING.
WE GIVE BABIES FEEDINGS A LOT OROGASTRICALLY.
WE PUT A TUBE DOWN WHEN THEY'RE FIRST BORN,
BECAUSE ONE, THEY MAY HAVE RESPIRATORY DISTRESS, THEY'RE PREMATURE
OR, ANYTIME THAT THEY SUCK ON THE BOTTLE, THEY GET, LIKE BLUE.
AGAIN, RESPIRATORY DISTRESS. THEY'RE NOT ABLE TO COORDINATE
THEIR SUCKING AND THEIR BREATHING AT THE SAME TIME.
AND SO, WE'LL OG THEM FOR A WHILE, OROGASTRIC FEEDING.
SO I WANT TO SHOW YOU WHAT THAT LOOKS LIKE, WHICH BY THE WAY,
I DID PASS THE TUBE ONE TIME THROUGH SOMEONE'S AIRWAY
AND I PUT IT DOWN IN THEIR AIRWAY, A LITTLE --
ANOTHER LITTLE CONFUSED OLD LADY AND ALL OF A SUDDEN
I JUST NOTICED HER LITTLE LIPS GETTING BLUER AND BLUER AND BLUER.
THERE WAS NO QUESTION THAT I WAS IN THE WRONG SPOT.
SHE COULDN'T TALK TO ME, SHE WAS CONFUSED.
BUT YOU WILL GET SIGNS THAT THINGS ARE NOT RIGHT.
AND THAT WAS THE SIGN I GOT WAS THE CIRCUMORAL CYANOSIS RELATED TO WRONG PATH.
SO, LOOK AT YOUR WHOLE CLIENT, DON'T JUST THINK, "OH GOOD, I'M DONE."
LOOK AT THEIR FACE, LOOK AT THEIR COLOR, LOOK AT THEIR RESPIRATION,
SEE HOW THEY'RE DOING BEFORE YOU JUST...
SAY, "OH, GOOD."
ALRIGHT, LET'S LOOK AT THIS VIDEO
WHERE THEY MAY KEEP IT IN AS AN NICU,
LITTLE TWO-POUNDERS, AND THEY ARE FEEDING THEM A LITTLE MORE CONSTANTLY.
AND THEY DON'T WANT TO TAKE HIM IN AND OUT,
SO THEY MAY LEAVE THAT ONE IN FOR A PHASE, KIND OF, THING.
BUT, MOST OF THE TIME, IT'S JUST BETTER TO TAKE IT OUT.
IT, KIND OF, CAUSES THEM TO GAG A LITTLE BIT SOMETIMES, AND THEN THEY ALSO SUCK ON IT.
AND SOMETIMES, THEY CAN'T COORDINATE EVEN THE SUCKING ON THE TUBE.
SO, JUST OUT.
SO QUICKLY, YOU'RE GOING TO HAVE A BABY STATION.
- GOING BACK TO THE -- - UH-HUH?
- TO THE SIZE OR THE NUMBER OF THE TUBE SIZE - YES?
- IN CASE SMALL DIAMETERS THAT ARE FRENCH.
- FRENCH. UH-UH. THAT'S THE OPPOSITE.
ON THE GAUGE IS THE BIGGER THE NUMBER, THE SMALLER THE NEEDLE.
BUT ON FRENCHES, THE SMALLER THE NUMBER, THE SMALLER THE GAUGE.
SO, LITTLE 5 FRENCHER IS WHAT YOU WOULD USE FOR A FEEDING
OR A LITTLE 8 FRENCHER.
AND THEY COME IN DIFFERENT LENGTHS, AS YOU CAN SEE.
AND THIS WOULD BE WHAT THEY MIGHT WANT TO USE IN A LITTLE --
IN AN NICU WHERE THEY PUT IT DOWN
AND THEN THEY HANG THE FEEDING ON TO A POLE AND SO YOU NEED MORE LENGTH.
BUT WHEN YOU'RE DOING JUST A LITTLE BY HAND, KIND OF, A DEAL,
AND YOU'RE JUST DOING IT REAL CLOSE, THEN THE LITTLE SHORT ONES WORK.
THE LITTLE 5 IS VERY LITTLE.
SO FORMULA PASSES EVER SO SLOWLY THROUGH A LITTLE 5.
THE 8S ARE NICE, IT MOVES PRETTY FAST.
BUT YOU DON'T WANT TO HAVE A FEEDING GO IN, IN ONE MINUTE
JUST BECAUSE YOU HAVE TO THINGS TO GO, PLACES TO SEE AND, YOU KNOW, STUFF.
SO YOU STILL NEED TO HAVE YOUR FEEDING TAKE AS LONG AS A FEEDING WOULD TAKE.
SO YOU'RE LOOKING AT 20 MINUTES FOR A FEEDING.
SO, SLOW ISN'T ALWAYS BAD.
IT KIND OF FORCES YOU TO TAKE THE TIME YOU NEED TO TAKE INSTEAD OF...
THERE, GOOD. ARE YOU HAPPY, BABY? WELL, YOU KNOW, IT NEEDS TO TAKE SOME TIME.
ALRIGHT, SO WE HAVE OUR DOCTOR'S ORDERS TO OG.
WE'RE GOING TO GATHER -- WASH YOUR HANDS,
GATHER UP YOUR EQUIPMENT AND I HAVE BOTH SIZES OF TUBES OUT AND AVAILABLE.
SO, ACTUALLY, I'M NOT EVEN GOING TO HAVE YOU GATHER ANYTHING FOR THIS ONE.
THE STATIONS WILL BE SET UP, YOU'LL JUST COME TO YOUR STATION
AND MAKE SURE EVERYTHING IS THERE, THAT SOME STUDENT DOESN'T WALK OFF WITH SOMETHING.
BUT EVERYTHING SHOULD BE THERE.
WE HAVE A LITTLE BASIN JUST TO CATCH OUR PH PAPER.
I HAVE A 30 CC -- 20 CC SYRINGE.
I HAVE WATER, I HAVE SOMETHING TO MEASURE THE WATER.
I HAVE SOME TAPE, I'LL GET A COUPLE OF PIECES OUT.
AND I HAVE A MEASURING TAPE TO MEASURE THE GIRTH.
YOUR ORDER IS, IN THE PRETEND WORLD OF FEEDING
THAT YOU'RE GOING TO GIVE 10 CC'S OF FORMULA,
BUT YOUR FORMULA IS GOING TO BE WATER,
BECAUSE THAT'S WHAT WORKS FOR OUR BABIES.
SO, WASH MY HANDS, GOING TO IDENTIFY MY CLIENT,
AND PROVIDE PRIVACY IF POSSIBLE IN THE NURSERY.
ONE OF THE THINGS YOU WANT TO BE SURE ABOUT WITH YOUR BABY
IS THAT WHEN YOU'RE DOING YOUR MEASURING AND HANDLING THE BABY,
MAKE SURE THE BABY HAS HAD THE FIRST BATH. IF THE BABY HAS NOT HAD THE FIRST BATH,
THEN YOU HAVE TO HANDLE THEM WITH GLOVES BECAUSE THEY HAVE MOTHER'S BODY FLUIDS ON THEM.
SO YOU CAN ASSUME OUR BABY IS CLEAN,
AND WE'RE JUST DOING A FEEDING, BUT THAT'S NOTEWORTHY.
ALRIGHT. THE FIRST THING WE WANT TO DO HERE
IS CHECK OUR IV BANDS.
AND I DON'T KNOW IF I EVEN HAVE ANY ON THESE.
WE HAVE SPECIAL LITTLE BABIES...
..ACTUALLY THEY'RE IN A LITTLE BASSINET LIKE THIS.
AND THEY'RE LITTLE TINY CHEAP BABIES I BOUGHT AT WAL-MART FOR, LIKE, 5 BUCKS.
BUT THEY HAVE HOLES SO THAT WE CAN PUT TUBES DOWN IN THEM.
SO YOU CAN MEASURE ON THE DIFFERENT SIZES.
SOME OF THESE OTHER BABIES DON'T HAVE HOLES IN THEIR MOUTH.
SO THAT'S A PROBLEM.
ALRIGHT. FIRST THING WE WANT TO DO IS WE WANT TO MEASURE THEIR ABDOMINAL GIRTH.
WHY DO YOU WANT TO DO THAT?
- FOR DISTENSION
- AGAIN, YEAH, CHECKING FOR DISTENSION.
CHECK TO SEE HOW THEY'RE HANDING IT.
AND SO GET YOUR ABDOMINAL GIRTH ON YOUR BABY.
YOU WANT TO LISTEN TO LUNGS AND BOWEL SOUNDS
SO THAT YOU HAVE A GOOD BASELINE
AS TO HOW THEY'RE TOLERATING THEIR FEEDING.
ALRIGHT. THE NEXT THING I WANT TO DO,
IF YOU TAKE YOUR BASSINETS, YOU CAN DROP THEM LIKE THIS,
AND THIS LITTLE BAR WILL KEEP THEM UP WHICH IS NICE FOR DOING YOUR FEEDINGS.
THE NEXT THING I WANT TO DO IS I WANT TO GET THE RIGHT MEASUREMENT FOR THE BABY.
AND THAT IS, I WANT TO TAKE FROM THE NOSE --
FROM THE EAR TO THE NOSE AND THEN BETWEEN
THE XIPHOID PROCESS IN THE UMBILICUS.
BECAUSE OF THE BABY ANATOMY,
WE NEED THE TUBE TO BE JUST A LITTLE BIT LONGER.
SO NOW IT'S NOT TOO XIPHOID, BUT RIGHT IN BETWEEN.
AND THEN ONCE WE HAVE THAT SPOT,
WE JUST WANT TO MARK IT WITH A LITTLE PIECE OF TAPE.
AND THEN YOU WANT TO PAPOOSE YOUR BABY NICE AND SNUG...
..SO THAT THEY DON'T SWAT AT THE TUBE.
SO, GRAB ONE END TIGHT, YOUR LITTLE TRIANGLE --
HAVE WE TALKED ABOUT THIS BEFORE? WE DID. OKAY.
AND THEN PUT YOUR BOTTOM, THE SCARFING UP AND THEN FINALLY THE LAST ONE.
SNUG, SNUG, SNUG. AND THEN...
..RIGHT SIDE.
AROUND THIS WAY.
OKAY, IF I'M GOING TO GIVE 10 CC'S OF FEEDING,
I'M GOING TO GO AHEAD AND MEASURE IT...
IN YOUR LITTLE BOTTLE, AND WE'LL JUST HAVE A BIG, OLD GLASS OF WATER LIKE THIS.
HERE WE GO.
AND SYRINGE.
GLOVES.
- DO YOU SHUT THE BULB SYRINGE OR [INDISTINCT]?
- THE BULB SYRINGE, YES, SHOULD BE IN HERE
AND I WAS JUST TAKING A QUICK RUN THROUGH MY LITTLE NURSERY.
THE BULB SYRINGE IS TO SUCTION IN CASE THEY WERE TO GAG
OR YOU FELT LIKE THEY WERE CHOKING ON SOMETHING.
AND I'LL GRAB SOME FOR YOU. AND WE ACTUALLY -- THIS IS, KIND OF, FUNNY.
I SWITCHED THESE 2 MODULES FOR THE FIRST TIME
BECAUSE NEXT WEEK'S MODULE IS SO HUGE. HUGE.
IT'S OUR LAST HUGE MODULE. AND IT'S ON RESPIRATION.
IT'S SUCTIONING AND WE DID THAT THE WEEK BEFORE ON SUCTIONING A BABY
AND I SHOULD HAVE PUT IT IN WITH THIS WEEK. SO, OOPS.
WE'LL GET IT NEXT WEEK.
ALRIGHT. I'M GOING TO GO AHEAD -- WELL, IT DOESN'T MATTER.
YOU CAN PLUG IT WITH THE SYRINGE OR YOU CAN PLUG THE ENDS ON THESE.
WHEN YOU PUT THESE DOWN A BABY'S MOUTH,
YOU CAN LUBRICATE IT WITH A LITTLE WATER,
BUT NOT WITH ANY K-Y JELLY. THAT'S GROSS.
IT'S JUST GOING DOWN THEIR MOUTH AND THEIR MOUTH IS WET. SO, ON THEIR RIGHT SIDE,
AND YOU WANT THEM ON THE RIGHT SIDE IN CASE THEY WERE TO THROW UP OR GAG
WHEN YOU STICK THIS IN YOUR -- DOWN THEIR THROAT.
AND YOU JUST PUT THIS ALONG THE BACK OF THEIR TONGUE IN THE SIDE OF THEIR MOUTH.
AND THEN YOU JUST PUT IT DOWN AND THEY'LL...
[SUCKING]
THEY'LL JUST START SUCKING IT RIGHT ON DOWN.
AND THEN YOU STOP WHEN IT'S RIGHT HERE AT THE TAPE.
NOW, I LIKE TO TAPE TO THE CHEEK...IMMEDIATELY.
I MIGHT HAVE EVEN ASTERISKED IT.
BUT I WANT TO MENTION THAT WHEN YOU TAPE,
TAPE ON THE UPPER CHEEK SO THAT YOU HAVE MORE LENGTH OF TUBING
RATHER THAN TAPE ON THE BOTTOM CHEEK.
AND YOU'D BE SURPRISED, HOW MANY BOTTOM CHEEK TAPERS. OKAY.
WE NEED THE UPPER CHEEK.
NOW, WE NEED TO CHECK FOR PLACEMENT
SO WE'RE GOING TO CONNECT OUR BULB SYRINGE HERE AND ASPIRATE STOMACH CONTENTS
AND SEE WHAT WE GET AS FAR AS RESIDUAL AND TO CHECK PH. HE DIDN'T CHECK PH,
BUT IT'S A LITTLE BIT OLDER TAPE, SO WE CAN STILL CHECK PH.
GET ALL THE RESIDUAL THAT YOU CAN, ALL IN ONE STEP, PLUG IT.
IF I GOT 4 CC'S, I'M GOING TO REMEMBER THAT.
CHECK MY PH.
MY PH IS GOOD. THEN I'M GOING TO RETURN MY RESIDUAL.
WHATEVER. 4 CC'S.
- YOU GOT 4 [INDISTINCT]. - PARDON ME?
- 4 IS [INDISTINCT], RIGHT? I DON'T UNDERSTAND WHY YOU'RE TAKING.
- IF THAT'S THE CASE, WE'LL GET THERE.
YEAH, AND THEN WE WOULD HOLD THE PD. BUT LET'S SAY 4 CC'S.
PLUG, AND THEN WE'VE GOT SOME CALCULATING TO DO.
SO, WE'RE GOING TO HOLD THE FEEDING AT WHAT?
- 25%. - 25%.
MORE THAN 25%, WHICH WOULD BE HOW MANY CC'S OF A 10 CC FEED?
- 2.5. - 2.5, SO WE GET TO HOLD THE FEEDING.
RIGHT? IF OUR RESIDUAL WAS 2 CC'S, WE CAN GIVE THE FEEDING.
IF THE RESIDUAL IS 2 CC'S HOW MANY CC'S OF FEEDING DO WE GIVE?
- 8 CC'S. - 8 CC'S.
SO, THEY NEVER JUST KEEP LOADING UP A STOMACH ON A BABY
WITH 4 PLUS 10 OR 2 PLUS 10 OR WHATEVER.
YOU SUBTRACT AND ALWAYS HAVE A TOTAL ON STOMACH.
- IF YOU'RE CHECKING FOR RESIDUAL,
WHAT'S THE POINT OF CHECKING FOR THE GIRTH AROUND THE STOMACH?
- TO SEE IF THERE'S -- - ISN'T IT THE SAME THING?
- JUST TO SEE THEIR STATUS, TO SEE IF THEY'RE BUILDING UP GAS,
TO SEE IF THEY'RE MOVING FLUIDS THROUGH.
IT'S AN ASSESSMENT TECHNIQUE TO SEE HOW DISTENSION
IS BEING RESOLVED OR NOT RESOLVED.
HOPEFULLY, IT WILL STAY THE SAME IF THEY'RE NOT HAVING A PROBLEM.
BUT IF THEY'RE COLICKY AND CRYING OR YOU'RE NOT SEEING STOOLS,
WHAT'S HAPPENING? IS THE GIRTH GROWING?
SO IT'S A POINT OF REFERENCE WHEN YOU'RE DOING SOMETHING
THAT'S NOT JUST FEEDING AND STOOLING.
ALRIGHT. WELL, LET'S SAY OURS WAS 2, WE CAN WORK WITH TWO.
SO WE NEED TO NOW GET RID OF 2 MORE AND MAKE IT 8,
OR YOU GOT NOTHING OR WHATEVER. YOU GET THE GIST.
OKAY. I REALLY DO WANT YOU TO PUT WATER IN.
BUT MY BABIES WILL MOLD IF YOU DO.
SO, WE'LL PULL IT OUT, KIND OF, QUICKLY LIKE THAT,
SO IT'S PRETEND IN THE STOMACH.
AND THEN...
..PUT YOUR FEEDING IN.
HMMM. NOTHING'S GOING.
DON'T CHEAT AND LOOK INTO THE BASIN.
YOU WOULDN'T HAVE A BASIN TO LOOK INTO, RIGHT.
SO DON'T CHEAT.
SO WHAT DO YOU DO IF IT'S NOT MOVING?
WELL, YOU GIVE IT A LITTLE PUFF. YOU DON'T PLUNGE IT IN,
BUT YOU GOT TO BREAK THE SEAL HERE.
AND SO JUST GIVE IT A LITTLE PUFF AND GET IT MOVING.
OH, COME ON ALREADY.
I THINK, THERE SHE BLOWS. OKAY.
I SAW MY FINALLY -- MY LITTLE BUBBLE WENT. AND NOW YOU JUST HOLD IT.
AND YOU CAN ADJUST THE SPEED, BY HOW HIGH YOU HOLD THE LITTLE TUBE.
- WHAT'S GOING ON THERE? THE PRESSURE IS -- THE PRESSURE IS --
- UH-HUH. BECAUSE OF THE SMALL DIAMETER OF THIS TUBE,
SOMETIMES THE AIR DOESN'T ALLOW THIS TO BREAK FREE.
SO YOU JUST, KIND OF, BREAK THAT SEAL.
THERE'S PROBABLY SOME PHYSIOLOGICAL EXPLANATION, I DON'T KNOW WHAT IT IS.
I JUST KNOW IT IS NOT MOVING AND I GOT TO DO SOMETHING ABOUT IT.
SO, JUST A LITTLE PUFF TO GET THINGS ROLLING. LET IT GO IN.
THEN YOU CAN FLUSH WITH WHATEVER THEY SAY
BECAUSE YOU WANT THEM TO GET ALL THEIR FEEDING, SO WHATEVER.
MAYBE 1 OR 2 CC'S OF WATER SO THAT THEY GET ALL OF THEIR FLUID.
OK. LET'S JUST SAY THEY DID.
THEN WHEN IT'S ALL DONE,
YOU WANT TO TAKE THIS OFF AND YOU WANT TO PLUG IT.
AGAIN, SO THAT YOU DON'T GET THE MIGRATING FLUID THAT COMES THROUGH.
TAKE IT OFF THE CHEEK AND THEN YOU JUST PULL IT STRAIGHT OUT OF THEIR MOUTH.
I DIDN'T MENTION MY PACIFIER. BUT I DO WANT TO MENTION THAT
YOU NEED TO HAVE A MANUFACTURED PACIFIER AND NOT A CREATED FROM A NIPPLE PACIFIER.
THEY USED TO, AND HOPEFULLY THEY DON'T ANYMORE,
PUT COTTON AND THEN JUST PUT THE LITTLE CARDBOARD SEAL
THAT CAME WITH THE PACIFIER AND LET THE BABY SUCK ON IT,
BECAUSE THEY DIDN'T HAVE ANY AROUND.
WHAT THEY FOUND WAS THAT THE BABIES WERE JUST SUCKING AIR,
BECAUSE OF A LITTLE CUT IN THE NIPPLE.
SO, YOU DON'T WANT TO USE A CREATED PACIFIER.
YOU WANT TO USE A REAL PACIFIER.
AND WE GET THEM FREE FROM THE FORMULA PEOPLE.
AND SO, YOU JUST NEED TO TELL THEM YOU NEED MORE.
ALRIGHT. ONCE YOUR BABY HAS...
..HAD THEIR FLUID, THEN YOU WANT TO GET THEM UP
AND BURP THEM A LITTLE, HOLD THEM, COMFORT THEM.
BURP. AND THEN PUT THEM ON THE RIGHT SIDE.
AND THEN I LIKE TO LEAVE THE HEAD OF THE BED UP FOR A LITTLE WHILE.
TAKE YOUR GLOVES OFF AND GET RID OF YOUR SUPPLIES.
TAKE YOUR GLOVES OFF, WASH YOUR HANDS AND THEN DOCUMENT ALL THE STUFF THAT YOU DOCUMENT.
OKAY? ALRIGHT. TESTS --