Basic Nursing Skills: Wound Care, Catheter Insertion, NG Tube Verification

Basic Nursing Skills: Wound Care, Catheter Insertion, NG Tube Verification

A practical, high-density guide for immediate clinical application.

What Is This?

This guide covers three essential nursing skills: - Wound care: Cleaning, dressing, and monitoring injuries to prevent infection and promote healing. - Catheter insertion (urinary): Placing a sterile tube into the bladder to drain urine when a patient cannot void naturally. - NG (nasogastric) tube verification: Confirming correct placement of a feeding tube inserted through the nose into the stomach.

These skills are critical for patient safety, infection control, and effective treatment in hospitals, long-term care, and home health settings.

Why It Matters

• Wound care: Poor technique leads to infections, delayed healing, and increased healthcare costs. Proper care reduces complications and hospital stays.
• Catheter insertion: Incorrect placement causes urinary tract infections (UTIs), trauma, or blockages. UTIs are the most common hospital-acquired infection.
• NG tube verification: Misplaced tubes can cause aspiration pneumonia, lung perforation, or malnutrition. Verification prevents life-threatening errors.

Mastering these skills improves patient outcomes, reduces legal risks, and enhances nursing confidence.

Core Concepts

Wound Care

1. Types of wounds:
2. Acute: Surgical incisions, lacerations, burns (heal in days/weeks).
3. Chronic: Pressure ulcers, diabetic foot ulcers (heal slowly, often recur).

4. Contaminated vs. clean: Dirty wounds (e.g., road rash) need debridement; clean wounds (e.g., surgical) need sterile technique.

5. Healing phases:

6. Inflammatory (0–3 days): Redness, swelling, pain. Body sends white blood cells to fight infection.
7. Proliferative (3–21 days): New tissue forms (granulation). Keep wound moist to support healing.

8. Maturation (21 days–2 years): Scar tissue strengthens. Protect from reinjury.

9. Dressing principles:

10. Moisture balance: Too dry = delayed healing; too wet = maceration (skin breakdown).
11. Debridement: Remove dead tissue (mechanical, enzymatic, or surgical).

12. Infection control: Sterile technique for acute wounds; clean technique for chronic wounds.

13. Signs of infection:

14. Increased pain, redness, warmth, swelling, purulent drainage, foul odor, fever.

Catheter Insertion (Urinary)

1. Indications:
2. Urinary retention (e.g., post-surgery, prostate enlargement).
3. Accurate output measurement (e.g., ICU, renal failure).

4. Incontinence management (e.g., pressure ulcers, palliative care).

5. Types of catheters:

6. Foley (indwelling): Balloon holds it in place; used for long-term drainage.
7. Straight (intermittent): No balloon; used for one-time drainage (e.g., post-void residual check).

8. Coude: Curved tip for enlarged prostates.

9. Sterile technique:

10. Contamination = UTI risk. Use sterile gloves, drapes, and antiseptic (e.g., chlorhexidine or povidone-iodine).

11. Anatomy landmarks:

12. Female: Urethra is short (~4 cm); locate between clitoris and vagina.

13. Male: Urethra is longer (~20 cm); advance catheter to the "Y" bifurcation before inflating balloon.

14. Complications:

15. UTI: Most common; prevent with sterile insertion and daily catheter care.
16. Trauma: Forceful insertion causes bleeding or false passages.
17. Blockage: Sediment or kinks obstruct flow; irrigate if needed.

NG Tube Verification

1. Purpose:

2. Ensure tube is in the stomach (not lungs or esophagus) before feeding or medication administration.

3. Verification methods (use at least two for accuracy):

4. X-ray: Gold standard; confirm before first use.
5. Aspirate pH test: Stomach pH-5.5; lung pH-6.0.
6. Air insufflation: Inject 10–30 mL air while auscultating over the stomach (listen for "whoosh").

7. Capnography: Detects CO? if tube is in the lungs (rarely used but highly accurate).

8. Signs of misplacement:

9. Coughing, choking, or respiratory distress (tube in lungs).
10. No aspirate or high pH (tube in esophagus or coiled in mouth).

11. Abdominal distension (tube in intestines).

12. Contraindications:

13. Facial trauma, esophageal varices, or recent nasal surgery.

How It Works

Wound Care Workflow

1. Assess: Measure size, depth, drainage (serous, sanguineous, purulent), odor, and surrounding skin.
2. Clean: Irrigate with normal saline (0.9% NaCl) or antiseptic (e.g., chlorhexidine). Use a 35-mL syringe and 19-gauge needle for pressure.
3. Debride: Remove necrotic tissue (scalpel, wet-to-dry dressings, or enzymatic agents like collagenase).
4. Dress: Choose based on wound type:
5. Dry wounds: Hydrogel or hydrocolloid.
6. Moderate drainage: Foam or alginate.
7. Infected wounds: Silver-impregnated or antimicrobial dressings.
8. Secure: Use tape, Montgomery straps, or tubular netting.
9. Document: Size (length × width × depth), drainage, odor, and patient response.

Catheter Insertion Steps

Equipment: Sterile catheter kit, sterile gloves, antiseptic, lubricant, syringe (10 mL for balloon), drainage bag, tape.

Female Patient

1. Position: Dorsal recumbent (supine, knees bent, feet flat).
2. Clean: Use antiseptic swabs (front to back: labia majora-labia minora-urethral meatus).
3. Insert: Hold catheter 2–3 inches from tip, advance 2–3 inches until urine flows, then advance 1–2 more inches.
4. Inflate balloon: Inject 10 mL sterile water (check kit for volume).
5. Secure: Tape catheter to thigh; hang bag below bladder level.

Male Patient

1. Position: Supine, legs slightly apart.
2. Clean: Retract foreskin (if uncircumcised), clean in circular motions from meatus outward.
3. Insert: Hold penis at 90° angle, advance catheter 7–9 inches until urine flows, then advance to the "Y" bifurcation.
4. Inflate balloon: Inject 10 mL sterile water.
5. Secure: Tape catheter to abdomen or thigh; replace foreskin.

NG Tube Verification Steps

1. Insert tube (see Hands-On).
2. Initial verification:
3. X-ray: Confirm placement before first use (mandatory in most facilities).
4. Ongoing verification (before each use):
5. Aspirate: Draw back with a syringe; check pH (? 5.5 = stomach).
6. Air insufflation: Inject 10–30 mL air while auscultating over the epigastrium (listen for "whoosh").
7. Observe: Check for coughing, respiratory distress, or tube coiling in mouth.
8. Secure: Tape tube to nose and cheek; mark exit site with indelible marker.

Hands-On / Getting Started

Prerequisites

• Knowledge: Anatomy (urinary tract, GI tract), infection control, sterile technique.
• Skills: Hand hygiene, donning sterile gloves, measuring output.
• Equipment:
• Wound care: Gloves, saline, dressings, tape, measuring tool.
• Catheter: Sterile kit, antiseptic, lubricant, drainage bag.
• NG tube: 14–18 Fr tube, water-soluble lubricant, syringe, pH strips, tape.

Step-by-Step: Wound Care

Scenario: Clean and dress a stage 2 pressure ulcer on the sacrum.

1. Assess:
2. Size: 3 cm × 2 cm × 0.5 cm.
3. Drainage: Serous (clear, watery).
4. Surrounding skin: Intact, no redness.
5. Clean:
6. Irrigate with 100 mL normal saline using a 35-mL syringe and 19-gauge needle.
7. Pat dry with sterile gauze.
8. Dress:
9. Apply hydrocolloid dressing (e.g., Duoderm) to maintain moisture.
10. Secure with tape or tubular netting.
11. Document: ```markdown
12. Location: Sacrum
13. Size: 3 × 2 × 0.5 cm
14. Drainage: Serous, scant
15. Dressing: Hydrocolloid
16. Patient tolerated procedure well. ```

Step-by-Step: Catheter Insertion (Female)

1. Prepare:
2. Open sterile kit; don sterile gloves.
3. Lubricate catheter tip (1–2 inches).
4. Clean:
5. Use antiseptic swabs: far labia-near labia-center (meatus).
6. Insert:
7. Hold catheter 2–3 inches from tip; advance until urine flows (~2–3 inches), then advance 1–2 more inches.
8. Inflate balloon:
9. Inject 10 mL sterile water; gently tug to ensure placement.
10. Secure:
11. Tape catheter to inner thigh; attach to drainage bag below bladder level.

Step-by-Step: NG Tube Insertion & Verification

1. Measure tube length:
2. Nose-earlobe-xiphoid process. Mark with tape.
3. Insert:
4. Lubricate tip; insert through nostril, aiming toward ear.
5. Have patient swallow water (if alert) to facilitate passage.
6. Advance to marked length.
7. Verify:
8. X-ray: Confirm placement (first use only).
9. Aspirate: Check pH (? 5.5).
10. Air insufflation: Inject 30 mL air while auscultating over stomach.
11. Secure:
12. Tape tube to nose and cheek; mark exit site.

Common Pitfalls & Mistakes

Wound Care

1. Over-cleaning:
2. Mistake: Scrubbing wounds aggressively damages granulation tissue.

3. Fix: Irrigate gently with saline; avoid harsh antiseptics (e.g., hydrogen peroxide).

4. Wrong dressing:

5. Mistake: Using a dry dressing on a draining wound causes maceration.

6. Fix: Match dressing to drainage (e.g., alginate for heavy exudate).

7. Ignoring undermining/tunneling:

8. Mistake: Measuring only surface size misses deep tissue damage.
9. Fix: Probe wound edges with a sterile cotton swab to assess depth.

Catheter Insertion

1. Forcing the catheter:
2. Mistake: Resistance-pushing harder causes trauma.

3. Fix: Stop, reassess anatomy, and try a Coude catheter if prostate is enlarged.

4. Inflating balloon in urethra:

5. Mistake: Pain or resistance during inflation = balloon in urethra.

6. Fix: Deflate balloon, advance catheter further, then reinflate.

7. Breaking sterile field:

8. Mistake: Touching non-sterile surfaces (e.g., bed rail) contaminates kit.
9. Fix: Keep hands above waist; discard kit if sterility is compromised.

NG Tube Verification

1. Relying on one verification method:
2. Mistake: Using only air insufflation (unreliable if tube is coiled in esophagus).

3. Fix: Combine pH test + X-ray (first use) + clinical signs.

4. Misinterpreting pH:

5. Mistake: pH 6.0 = stomach (actually lung or intestinal).

6. Fix: Stomach pH-5.5; lung pH-6.0.

7. Not securing the tube:

8. Mistake: Tube migrates into lungs or esophagus.
9. Fix: Tape securely and mark exit site.

Best Practices

Wound Care

• Moisture balance: Use hydrocolloids or foams to keep wounds moist but not wet.
• Offload pressure: Reposition immobile patients every 2 hours to prevent pressure ulcers.
• Debride regularly: Remove necrotic tissue to prevent infection and promote healing.
• Document changes: Note size, drainage, odor, and patient pain level at each dressing change.

Catheter Insertion

• Use smallest catheter possible: Reduces trauma and UTI risk (e.g., 14 Fr for most adults).
• Secure properly: Prevents traction on urethra (tape to thigh or abdomen).
• Empty bag regularly: Prevents backflow and infection (every 4–6 hours or when 2/3 full).
• Remove ASAP: Catheters increase UTI risk; discontinue when no longer needed.

NG Tube Verification

• X-ray first: Always confirm placement with X-ray before first use.
• Check residuals: Aspirate stomach contents before feeding; hold if > 250 mL (varies by facility).
• Flush regularly: Use 30 mL water before/after feedings or medications to prevent clogs.
• Monitor for displacement: Check tape and exit site at least every 4 hours.

Tools & Frameworks

Real-World Use Cases

1. Post-Surgical Wound Care

• Scenario: Patient with a 5-cm abdominal incision post-appendectomy.
• Action:
• Clean with saline, apply sterile gauze, and secure with tape.
• Monitor for signs of infection (redness, fever).
• Switch to hydrocolloid dressing once drainage decreases.
• Outcome: Heals by primary intention in 7–10 days with no complications.

2. Urinary Retention in ICU

• Scenario: Patient with acute urinary retention post-spinal surgery.
• Action:
• Insert 16 Fr Foley catheter using sterile technique.
• Secure to thigh; empty bag every 4 hours.
• Remove catheter within 24 hours of voiding trial to reduce UTI risk.
• Outcome: Restores normal urine output; no UTI or trauma.

3. Enteral Feeding in Stroke Patient

• Scenario: Patient with dysphagia post-stroke requires NG tube feeding.
• Action:
• Insert 14 Fr NG tube; confirm placement with X-ray.
• Verify pH-5.5 before each feeding.
• Flush with 30 mL water before/after feedings.
• Outcome: Safe, effective nutrition delivery; no aspiration pneumonia.

Check Your Understanding (MCQs)

Question 1

A patient has a stage 3 pressure ulcer with moderate serosanguineous drainage. Which dressing is most appropriate? -