Nursing Practice
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Questions Received:
What is the nursing care preoperatively of a patient having laparotomy?
What is the post operative care of a patient having a lower anterior bowel resection?
Responses:
11th February 1999
Anyone working in a field which involves intimate contact with patients would be expected to convey sensitivity and respect for the patient's feelings. Aside from the possession of technical expertise patients have a right to expect that due care and concern will be given towards their need for privacy and comfort, both physically and psychologically.
Experiencing an erection whilst undergoing a rectal examination to determine prostatic function is not altogether unusual, particularly in view of the fact that the whole procedure also involved handling the genitalia. Again, people working as either doctors, nurses or technicians are aware that such a response can be inadvertently provoked when they are performing such procedures. For a patient this can be embarrassing but it is important to realise that the staff are not embarrassed, and accept that such reactions can quite easily occur.
The only part in the procedure that I can think of which might have eased your embarrassment would have been, if the technician had asked you to hold your penis away from the area being examined.
What is the nursing care pre-operatively of a patient having laparotomy?
16th March 1999
A Nursing Model appropriate to a particular practice setting would be used. The assessment, planning and nursing intervention strategies would depend on whether the person was about to undergo emergency laparotomy, or whether the surgery was planned in the sense that the person had been admitted from the Waiting List.
The general preparation would be the same as for any other operation requiring the administration of a general anaesthetic. Additional points to consider would be:
Psychological Care (core
areas):
Provide specific information about the procedures that are to be conducted on
the person both before and after surgery. Check that informed consent has been
given, and that the person understands what has been said. Give preoperative
teaching regarding the activities that the person can aim to perform after the
immediate pre-operative period, e.g. deep breathing exercises, movement of
limbs, operating a patient-controlled analgesic pump. Provide information
regarding the anticipated day of operation and expected length of stay.
Physical Care (core areas):
Safety - establish identity of the person and attach identity bracelet.
Objective Assessment - conduct baseline observations concerning temperature, pulse, blood pressure, weight, urinalysis, pressure risk assessment score, and body mass index. Important to verbally communicate any significant changes in these to the medical team.
Body Hygiene - removal of body hair is only to be undertaken if this is an established procedure within the particular practice setting. Thorough attention to body hygiene is essential. Check the integrity of the person's skin.
Eating & Drinking - a normal diet may be permissible up until 3-4hrs prior to surgery. Nil-by-Mouth after this period BUT according to local hospital policy. Intravenous fluids - usually crystalloid solutions set up on induction of the anaesthetic.
Elimination - a record of fluid output may be required. For surgery on the large bowel a high enema or rectal washout will be required. Also oral solutions may be prescribed to be given pre-operatively e.g. Picolax. Again local policies will need to be upheld.
Rest & Sleep - in view of the non-therapeutic aspects of enforced rest which an operation brings, compression stockings and anticoagulants such as mini-hep or fragmin may be prescribed pre-operatively to combat the risk of thromboembolic disease.
Prescribed
pre-operative drugs would be administered. Normally these consists of an opioid
analgesic, a substance to block parasympathetic stimulation and dry up
secretions e.g. Atropine, and/or a benzodiazepine e.g. diazepam or midazolam.
Patients should be warned not to get out of bed once these substances have been
given. The nurse call-bell will be placed within the patient's reach. The
pre-operative check list will now be completed.
Suggested Reading
Wicker, P. (1995) Pre-operative visiting, making it work. British Journal of Theatre Nursing, 15(7), 16-19.
What is the post operative care of a patient having a lower anterior bowel resection?
16th March 1999
Post-operative aim: to achieve a safe and uncomplicated transition from a period of high dependency to one of independence.
A Nursing Model which is recognised and approved by the nursing team would be implemented. Care for the patient would require a nursing history and assessment to be undertaken. Care planning, implementation and evaluation would be integral to the framework for care.
Within the Recovery Unit:
Communication - clear and concise information from the Theatre Nurse handing over the patient will be essential, particularly in relation to:
The identity of the patient
The surgical procedure performed
Vital signs and level of consciousness
Oxygen requirements
Drugs administered
Intravenous infusion therapy
Fluid out-put
The wound and wound drains
It will be important to communicate the person's care details in a quiet and controlled manner, keeping in mind that hearing is the first sense to return. Sensitivity concerning the patient's potential ability to hear, but not respond, is an important consideration.
Breathing - maintenance of the airway until the full return of the patient's protective reflexes will be paramount. Observing the respiratory rate, level of tissue perfusion (as revealed by changes in skin colour) and administering prescribed oxygen are key considerations. Familiarity with the equipment to deal with any respiratory complications will be essential. When the person is able to maintain their own airway observations continue. Listening during inspiration and expiration, feeling expired air against the back of the hand and observing colour are valuable checks. Oximetery will indicate the degree by which oxygen therapy is being effective. Naloxone Hydrochloride will be kept nearby and, if necessary, administered according to the instructions of the Anaesthetist.
Monitoring/evaluating (to influence care planning) - the patient will be in a degree of shock, both hypovolaemic and neurogenic. Monitoring reveals the degree of shock the person is in and the extent to which medical and nursing interventions are being effective. The pulse and blood pressure are recorded regularly e.g. 5-10 minutes initially, the frequency lessening in response to improvements. A rising pulse rate and falling blood pressure are indications that shock is progressing and urgent nursing/medical intervention is required. Drainage from wound drains e.g. vacu-drains will be carefully observed, excessive drainage will be reported. The patient's abdominal wound will periodically be carefully checked for signs of leakage.
Rest and sleep - it will be necessary to ensure that uninterrupted rest can be achieved. Communicating with the patient to determine the degree by which they are pain free and not experiencing discomfort is essential. A Pain Score Chart will be used and prescribed opiates given accordingly. Monitoring the patient's response to these preparations will be essential.
A Patient Controlled Analgesic device may be in use. Regular checks will be conducted on infusion pumps to ensure that these are working correctly.
Reorientating the person is essential and giving information to lessen stress and anxiety should help the accomplishment of psychological and therefore physical rest. (Point to ponder: To what extent does rest contribute towards healing?)
Eating and drinking - as the person will have developed paralytic ileus nothing will be given by mouth until peristalsis resumes. Sips of water only, may though be permitted. The stomach will be kept empty by the use of a naso-gastric tube which will be regularly aspirated and/or kept on free drainage. The amount of aspirate will be regularly recorded. Intravenous fluids will be administered as prescribed. A blood transfusion may be in progress, in which case transfusion observations will be taken and recorded. All fluid administered intravenously must run to time e.g. 1,000ml. over 8 hrs.= 41drops per minute. Anti-emetic preparations e.g. Prochlorperazine (A phenothiazine-related preparation) 12.5mg. I.M. 4-6 hrly. will, if necessary, be administered and the patient's response observed and recorded.
Eliminating - fluid output will be recorded. The urinary output during the first 6-12 hrs. postoperatively may be reduced in response to the stress of surgery - anti-diuretic hormone (ADH) release from the posterior pituitary gland is increased. The ADH acts on the distal convoluted tubules making these less permeable to water, and as a result less urine is produced. As the patient's state of hydration improves, less ADH is produced and an improved diuresis occurs. Signs of worsening oliguria or the development of anuria must be immediately communicated to the medical team.
The patient will remain in the Recovery Unit until both the Anaesthetist and the Nursing Team decide that the patient can return to the ward. The overriding considerations are that the patient is physiologically stable, pain free and able to maintain their own airway. The Recovery Room Nurse will then carefully hand the patient over to the ward Nursing Team.
Within the Ward:
In the ward the care is to a certain extent an extension to that which was established in the Recovery Unit.
Following a period of rest, support and monitoring, the patient is gradually encouraged to become a partner in their care. Effective pain control and anti-emetic measures should help towards the attainment of early mobilisation, and therefore lessen the risks associated with enforced rest.
Two final points to consider:
As a rule of thumb the patient's level of consciousness and degree of alertness are reasonable indicators of underlying tissue perfusion
People can become "vulnerable" once opiate administration is terminated and non-opiates are given. Pain breakthrough at this stage must be avoided. Similarly patient's can sometimes, in my experience, perceive that their care requirements are less once this milestone has been reached. This can unwittingly lead to feelings of vulnerability and insecurity, a pitfall to avoid.
Reading
Allcock. N. (1996). Factors affecting the assessment of postoperative pain. A literature review. Journal of Advanced Nursing, 24, 1144-1151.
Aronson, J.K., and Grahame-Smith, D.G. (1994) Oxford textbook of clinical pharmacology and drug therapy (2nd edition). Oxford: Oxford University Press. (p. 466, Table 33.1: Drugs used in anaesthesia).
31st March 1999
The doctor will have prescribed either an infusion or a transfusion for a patient to receive and the duration (the time over which the volume should be administered e.g. usually 8 hours for a litre (1,000 ml) or 4 hours for a half-litre (500 ml) ). One unit of blood has a volume of 450 ml.
The administration set selected will depend on whether an infusion or a transfusion is to be administered. For a crystalloid solution such as normal saline or dextrose saline a solution set will be used. These normally deliver 20 drops per ml. For a colloid solution e.g. blood, a blood administration set will be used and these deliver 15 drops per ml. However, it is always important to read the manufacturer's instructions.
The total volume is converted into drops. Therefore, if a crystalloid solution of 1,000ml. is prescribed and the administration set delivers 20 drops per ml, then in 1,000 ml there will potentially be 20,000 drops.
The duration is converted into minutes. If this is 8 hours then multiplying this by 60 = 480 minutes. The total number of drops in the given volume - 20,000 - is then divided by the duration - 480 minutes. This gives a figure of 41. Therefore the flow control rate will be set to deliver 41 drops per minute.
When running an infusion or a transfusion to the prescribed time it is very important to minimise the risk of either fluid overload or a shortfall occurring. Also once the oral route is bypassed for fluid administration the person undergoing the procedure will not be able to say when they have had enough, as they would if the fluid were to be offered by mouth.
Fluid Prescription Sheets normally show the rates at which administration flow control devices should be set. However, it is useful to have the above simple formula in mind to double check ... after all printing errors can sometimes occur!
8th April 1999; revised 26th April 1999
Intravenous Infusion - Nursing Perspectives
Preparation of the patient/client
Psychological - an explanation of the procedure, including rationale: what the person can do to enable the procedure to run smoothly, what they should avoid doing, and roughly how long the infusion will be in progress. The potential effects of the procedure on the patient's relatives should also be taken into account. For example, parents might be alarmed by the fact that their child is attached to an intravenous infusion. psychological - an explanation of the procedure, including rationale: what the person can do to enable the procedure to run smoothly, what they should avoid doing, and roughly how long the infusion will be in progress. The potential effects of the procedure on the patient's relatives should also be taken into account.
For
example, parents might be alarmed by the fact that their child is attached to an
intravenous infusion. psychological - an explanation of the procedure, including
rationale: what the person can do to enable the procedure to run smoothly, what
they should avoid doing, and roughly how long the infusion will be in progress.
The potential effects of the procedure on the patient's relatives should also be
taken into account. For example, parents might be alarmed by the fact that their
child is attached to an intravenous infusion.
Physical - preparation of the skin surface over which the cannula is to be sited (normally over the back of the hand or forearm). physical - preparation of the skin surface over which the cannula is to be sited (normally over the back of the hand or forearm). physical - preparation of the skin surface over which the cannula is to be sited (normally over the back of the hand or forearm).
This may involve removal of any hair as adhesive tape should not be applied over body hair. The doctor is normally the person responsible for inserting an intravenous cannula. However, nurses are beginning to take on this procedure as an extended role in the U.K. A local anaesthetic or topical anaesthetic cream (eg: EMLA or Ametop) may be offered to ease the pain which cannulation can produce.
Safety
The following checks need to be made:
the patient's identity will be checked before the procedure begins and whenever containers of fluid are changed
The fluid to be administered will be checked against the patient's identity and the fluid prescription sheet
Monitoring
The prescribed fluid will be delivered over the stated duration
A record of all fluid administered and urine passed will be kept. Any degree of fluid imbalance will be reported to the doctor
The patient's temperature, blood pressure, pulse and respiratory rate will be recorded regularly throughout the procedure
The cannula site will be regularly checked for signs of inflammation and extravasation.
Equipment
The procedure involves the use of:
An intravenous cannula of the appropriate size
A fluid administration set
The prescribed fluid
The prescription sheet
A fluid balance chart
A temperature, pulse and blood pressure chart
N.B. The procedure requires an aseptic approach and appropriate measures to reduce the risk of contamination must be upheld throughout.
Solutions
Crystalloids - isotonic solutions are commonly prescribed, eg sodium chloride 0.9%, sodium chloride 0.18% glucose 4%. N.B. Solutions containing intravenous potassium eg: 20 mmols per litre may be prescribed to correct hypokalaemia. Great care must be taken not to confuse "plain" crystalloid solutions with those containing potassium
Colloids (plasma replacers and expanders) - Gelofuscine, Haemaccel, dextrans, heptastarch and pentastarch may be prescribed in the management of intravascular volume replacement or hypovolaemic shock.
Anaesthetics - Nursing Perspectives
Nursing practice frequently involves the care of patients who have to undergo procedures which necessitate the use of a general anaesthetic. Nurses are involved in caring for such people in the pre-operative, intra-operative and post-operative phases. The provision of such care requires skill and precision. Nurses not only have to administer quite potent drugs during the pre- and post-operative phases, they need also to possess a comprehensive knowledge of the therapeutic and non-therapeutic effects of these preparations. In addition, a knowledge of the drugs administered by the anaesthetist is required.
Psychological Preparation
It is essential that the patient is given as much information as is thought necessary beforehand. Informed consent must be obtained and a consent form signed. Usually this is carried out by the doctor. The age at which consent may be given is sixteen (within the U.K.). For people below this age the consent of the parent or guardian must be obtained. Legally, however, those under 16 may be deemed responsible to give consent. It is important that the process of information giving and signing of the consent form is completed before any pre-medication is administered.
Premedication
Not all operations necessitate the administration of a premedication. Previously premedication was commonplace but practice is changing. Although for the majority of operations anaesthetists still prescribe a premedication, there are occasions when the patient may be allowed to choose. In some instances the pre-medication may be given on induction. Drugs from the following groups may be prescribed:
Anxiolytic Benzodiazepines eg: Diazepam, Temazepam
Opioid Analgesics - eg: Morphine, Papaveretum, Pethidine
Anticholinergic Drugs - eg: Atropine, Hyoscine
Antiemetics - eg: Metoclopramide
Drugs such as Diazepam and Morphine bring about changes in the person's mental state. As a result the patient's anxiety can be lessened and a state of calm induced. Morphine will also provide pain control, particularly during the intraoperative period. The anticholinergic drug Atropine may be prescribed. This preparation acts on the parasympathetic nerves supplying the salivary glands, peventing secretion. It is important to protect the person from noise and nuisance after such preparations have been given. Ideally the person should arrive in the Anaesthetic Room in a quiet, calm and fairly relaxed state.
Anaesthetics
Anaesthesia produces a state of insensibility. This state of insensibility must be controllable and reversable. The administration of anaesthetic agents produces: unconsciousness, analgesia and if necessary muscular relaxation.
Induction is normally
achieved by administering a barbiturate preparation, eg: Thiopentone.
However, other substances may be used to achieve a state of unconsciousness,
eg: Propofol. Once unconsciousness has been achieved protection and
maintenance of the person's airway becomes mandatory. Muscular relaxation is
achieved by administering either a non-depolarising drug, eg: Atracurium, or
a depolarising drug such as Suxamethonium. At this stage endotracheal
intubation is performed and the patient attached to a Positive Pressure
Ventilator. Other patients may breathe spontaneously, for example by a
laryngeal mask airway induction is normally achieved by administering a
barbiturate preparation, eg: Thiopentone.
However, other substances may be used to achieve a state of unconsciousness,
eg: Propofol. Once unconsciousness has been achieved protection and
maintenance of the person's airway becomes mandatory. Muscular relaxation is
achieved by administering either a non-depolarising drug, eg: Atracurium, or
a depolarising drug such as Suxamethonium. At this stage endotracheal
intubation is performed and the patient attached to a Positive Pressure
Ventilator. Other patients may breathe spontaneously, for example by a
laryngeal mask airway induction is normally achieved by administering a
barbiturate preparation, eg: Thiopentone. However, other substances may be
used to achieve a state of unconsciousness, eg: Propofol. Once
unconsciousness has been achieved protection and maintenance of the person's
airway becomes mandatory. Muscular relaxation is achieved by administering
either a non-depolarising drug, eg: Atracurium, or a depolarising drug such
as Suxamethonium. At this stage endotracheal intubation is performed and the
patient attached to a Positive Pressure Ventilator. Other patients may
breathe spontaneously, for example by a laryngeal mask airway.
Maintenance - balanced
anaesthesia is normally practised. This is achieved by administering a gas
such as nitrous oxide and oxygen with or without a volatile agent such as
Isoflurane. Opioid analgesics and additional doses of a muscle relaxant may
be given at intervals during the operation. Total intravenous anaesthesia (TIVA)
where the patient breathes oxygen enriched air is becoming more commonplace.
Critical monitoring of the patient's physical condition is continuous
throughout the operation. maintenance - balanced anaesthesia is normally
practised. This is achieved by administering a gas such as nitrous oxide and
oxygen with or without a volatile agent such as Isoflurane. Opioid
analgesics and additional doses of a muscle relaxant may be given at
intervals during the operation. Total intravenous anaesthesia (TIVA) where
the patient breathes oxygen enriched air is becoming more commonplace.
Critical monitoring of the patient's physical condition is continuous
throughout the operation. maintenance - balanced anaesthesia is normally
practised. This is achieved by administering a gas such as nitrous oxide and
oxygen with or without a volatile agent such as Isoflurane. Opioid
analgesics and additional doses of a muscle relaxant may be given at
intervals during the operation. Total intravenous anaesthesia (TIVA) where
the patient breathes oxygen enriched air is becoming more commonplace.
Critical monitoring of the patient's physical condition is continuous
throughout the operation.
Recovery
The effects of the anaesthetic agents are reversed. The anaesthetic gases and
vapours are switched off and the patient breathes an oxygen enriched mixture.
Neostigmine may be given to reverse the effects of non-depolarising muscle
relaxants. Naloxone hydrochloride may be given to treat respiratory depression
if this emerges as a result of opioid administration. The drug Flumazenil may be
given to reverse the effects of benzodiazepines. Protection from pain is
mandatory also at this stage and post operative opiate administration together
with the regular administration of anti-emetics begins. Airway protection,
monitoring vital signs and administering prescribed drugs together with
maintaining infusions/transfusions are all important nursing priorities at this
stage. Frequently local anaesthetic and regional techniques such as epidural
infusions or patient controlled analgesia (PCA) are used to achieve
post-operative pain relief.
Bibliography
Aronson, J.K., and Grahame-Smith, D.G. (1994) Oxford Textbook of Pharmacology and Drug Therapy (2nd edition). Oxford: Oxford University Press. (General anaesthetics and local anaesthetics pp. 465-468.)
British National Formulary (1996) Number 32 (September). London: British Medical Association and the Royal Pharmaceutical Society of Great Britain. (15: Drugs used in anaesthesia pp. 519-523.)
We would like to thank Dr Stephen Hunter BSc FRCA, Consultant Anaesthetist, Yeovil District General Hospital, Yeovil, Somerset for his advise and guidance with this answer.
13th April 1999
Cystoscopes are precision optical instruments and are not robust enough to be sterilised. Therefore chemical disinfection (for example with glutaraldehyde) becomes the only practical way to ensure that the risk of pathogenic contamination of the urinary tract is kept to an absolute minimum. Understandably, this constraint can lead practitioners to question the justification behind the use of sterile gloves when handling a cystoscope, and the need to provide a sterile surface.
One way of viewing the rationale behind this approach is to think about the consequences of contamination. Should contamination occur following the usual disinfection procedure for cystoscopes and the handling of the scope with sterile gloves combined with the use of a sterile field, then the disinfection procedure would be the only likely source. If contamination were to occur under circumstances where clean gloves and a clean field had been the practice then these two areas would also have to be considered.
Therefore it is suggested that by providing the ultimate environment (sterile field and sterile gloves) the potential risks of contamination are reduced. As a result, the patient/s are then offered the best possible standard of care.
Suggested reading: Decontamination of Urological Equipment, Interim report of the Standing Committee on Urological Instruments. British Journal of Urology, 71. (5 September 1993)Suggested reading: Decontamination of Urological Equipment, Interim report of the Standing Committee on Urological Instruments. British Journal of Urology, 71. (5 September 1993)
We would like to thank Mrs. Tracey Cooper, Infection Control Nurse, Royal Devon & Exeter Healthcare N.H.S.Trust, Wonford, Exeter, Devon EX2 5DW for her help in compiling this response.
12th May 1999
The following is a personal view, based on the limited information given and my experience as a nurse. It is not intended to act as a substitute for professional advice either from a professional organisation or a member of the legal profession.
Although the nurse did not administer the drug she/he did draw the preparation up ready for administration and as such played a 'key' part in the procedure. Under these circumstances it is assumed that the nurse is competent in carrying out the stages of preparation and that she/he understood the prescription and possessed knowledge of the drug and the dose. Both the nurse and the doctor are under a duty to ensure that the correct drug, at the correct strength, is given to the correct patient at the correct time and by the correct route. Although the drug was handed across by the nurse to the doctor for him/her to administer one would expect the nurse to prepare the drug correctly, and that both parties would jointly go through the regime of checks already stated before administering the drug. Not to do so could be construed as acting unreasonably and therefore I think the nurse may be culpable.
6th November 1999
Weighted intestinal tubes for parenteral nutrition were developed to facilitate duodenal intubation and to reduce the risk of aspiration into the bronchi. The Miller-Abbot tube which you refer to has not been used in my experience (which has been confined to just three District General Hospitals in the U.K.) since the early 1960's. The Miller-Abbot tube was designed by two American physicians, Thomas Miller (1886-1981) and William Abbot (1902-1943). This is a double lumen tube used as method for achieving intestinal decompression (Mosby 1998, p.1035). The Harris tube, developed by an American surgeon Franklin Harris (b.1895) is a mercury weighted tube used for gastric and intestinal decompression. The amount of mercury situated in the soft bag which surrounds the tube varies from 2-5ml. according to age, size and condition of the patient. The Cantor tube was designed by Meyer Cantor, an American physician (b.1907). This is a double lumen tube which has a rubber bag at one end and is used to relieve obstruction in the small bowel (Mosby 1998, p. 256). I have not encountered either of these in practice.
The pre-packed disposable Ryle's type of naso-gastric tube is now the more common tube used for achieving gastric aspiration and facilitating decompression within the lower gastrointestinal tract. Given the potential hazards of mercury use, other materials such as tungsten tend to be used now if a weighted tube is required (Ugo, Mohler, and Wilson, 1992).
Comparisons have been made between weighted and unweighted tubes, but a consensus has not yet been reached on their relative merits. For example, Jimenez et al (1993) reported that weighted tubes showed greater effectiveness in duodenal intubation rate and the time they remained in the body, while Silk et al (1987) and Levenson et al (1988) found no advantage of weighted tubes over unweighted tubes. Lord et al (1993) obtained better transpyloric passage with unweighted tubes.
Several methods for the post-pyloric positioning of enteral feeding tubes have been evaluated. Tubes are often introduced by nursing staff without visual or radiological control. A prospective study by Christen and Hess (1996) demonstrated that this method suffices in most instances, while checking by an experienced person adds to safety. They suggest that radiological control can be safely limited to cases in which there was a problem in positioning the tube or when the clinical control was unclear. Endoscopic techniques are being used increasingly (Kim, 1985; Gowen et al, 1987; Rees et al, 1988; Snyder et al, 1990; Mathus-Vliegen et al, 1993; Lo and Shinya, 1993; Kwauk et al, 1996). In a new technique, Gabriel et al (1997) modified a standard nasoenteral feeding tube by inserting a small magnet into the distal tip. The tube could then be guided into position by an external magnet placed over the abdomen. Transpyloric placement was achieved in the majority of cases.
Metoclopramide improves gastric emptying, and has been given to patients prior to tube insertion to facilitate passage of the tube through the stomach and into the duodenum (Whatley et al, 1984).
References
Christen, S., and Hess, T. (1996) Is a clinical positional control for nasogastric tubes good enough? A prospective study of 43 patients. [Article in German] Dtsch Med Wochenschr, 121(37), 1119-1122 (Sep 13).
Gabriel, S.A., Ackermann, R.J., and Castresana, M.R. (1997) A new technique for placement of nasoenteral feeding tubes using external magnetic guidance. Critical Care Medicine, 25(4), 641-645 (Apr).
Gowen, G.F., DeLaurentis, D.A., and Stefan, M.M. (1987) Immediate endoscopic placement of long intestinal tube in partial obstruction of the small intestine. Surgical Gynecology and Obstetrics, 165(5), 456-458 (Nov).
Jimenez, C., Gonzalez-Huix, F., Auger, E., Bou, R., Pons, N., Vila, N., Figa, M., and Acero, D. (1993) A prospective randomized study of the usefulness of weighted versus unweighted feeding tubes. A comparison of the transpyloric passage capacity, duration time and the signs of intolerance for enteral nutrition. [Article in Spanish] Nutr Hosp, 8(4), 249-255 (Apr).
Kim, I.G. (1985) Endoscopic guided intubation of long nasointestinal decompression tube. Surgical Gynecology and Obstetrics, 161(3), 282-284 (Sep).
Kwauk, S.T., Miles, D., Pinilla, J., and Arnold, C. (1996) A simple method for endoscopic placement of a nasoduodenal feeding tube. Surgical Endoscopy, 10(6), 680-683 (Jun).
Levenson, R., Turner, W.W. Jr., Dyson, A., Zike, L., and Reisch, J. (1988) Do weighted nasoenteric feeding tubes facilitate duodenal intubations? JPEN Journal of Parenteral and Enteral Nutrition, 12(2), 135-137 (Mar-Apr).
Lo, A.Y., and Shinya, H. (1993) Endoscopic placement of long intestinal tubes. American Surgery, 59(9), 626-627 (Sep).
Lord, L.M., Weiser-Maimone, A., Pulhamus, M., and Sax, H.C. (1993) Comparison of weighted vs unweighted enteral feeding tubes for efficacy of transpyloric intubation. JPEN Journal of Parenteral and Enteral Nutrition, 17(3), 271-273 (May-Jun).
Mathus-Vliegen, E.M., Tytgat, G.N., and Merkus, M.P. (1993) Feeding tubes in endoscopic and clinical practice: the longer the better? Gastrointestinal Endoscopy, 39(4), 537-542 (Jul-Aug).
Mosby (1998) Mosby's Medical, Nursing & Allied Health Dictionary (5th edition). St. Louis: Mosby-Year Book, Inc.
Rees, R.G., Payne-James, J.J., King, C., and Silk, D.B. (1988) Spontaneous transpyloric passage and performance of 'fine bore' polyurethane feeding tubes: a controlled clinical trial. JPEN Journal of Parenteral and Enteral Nutrition, 12(5), 469-472 (Sep-Oct).
Silk, D.B., Rees, R.G., Keohane, P.P., and Attrill, H. (1987) Clinical efficacy and design changes of "fine bore" nasogastric feeding tubes: a seven-year experience involving 809 intubations in 403 patients. JPEN Journal of Parenteral and Enteral Nutrition, 11(4):378-83 (Jul-Aug).
Snyder, C.L., Ferrell, K.L., Goodale, R.L., and Leonard, A.S. (1990) Nonoperative management of small-bowel obstruction with endoscopic long intestinal tube placement. American Surgery, 56(10), 587-592 (Oct).
Ugo, P.J., Mohler, P.A., and Wilson, G.L. (1992) Bedside postpyloric placement of weighted feeding tubes. Nutrition in Clinical Practice, 7(6), 284-287 (Dec).
Whatley, K., Turner, W.W. Jr., Dey, M., Leonard, J., and Guthrie, M. (1984) When does metoclopramide facilitate transpyloric intubation? JPEN Journal of Parenteral and Enteral Nutrition, 8(6), 679-681 (Nov-Dec).