G-tube replacement check sheet
G-tube replacement Date:
Patient: Age: (M/F) Room:
Comorbidities:
Physician order for the G-tube replacement:
Consent: patient / facility /
Removal:
- Last medication administration time:
- Patient body position (supine):
- Tube size:
- Balloon size:
- Tube is freely movable:
- Fluid aspiration, pH level (1 – 5.5):
- Sign of infection:
- Time of Removal:
Equipment:
- Tube size:
- Tube expiration date:
- Balloon size:
- External retention ring (disk stopper) is freely movable:
Insertion:
- Time of Insertion:
- Anesthesia:
- Resistance:
- Pain:
- Tube is freely movable:
- Placement: gastric fluid pH level (1 – 5.5)
- Position change backed to 30 degree angle or up-right
- Flush water:
- Skin condition:
- Dressing coverage:
- Did the patient tolerate the procedure?
- X-ray:
S/p G-tube replacement monitoring in 72 hours:
- Pain or distress after the replacement
- Pain or distress with feeding
- Fluid leaking
- Bleeding
Clinician name:
Preparation
- Physician order
- Consent
- G-tube kit
- Sterile water
- pH paper (x2)
- 60 ml syringe
- 10 ml syringe
- lubrication
- Gauze
- PPE
- Drain pad
