Enteral Therapy ( Chap 31) Flashcards
Of the patients listed below, which would be a candidate for nasoenteric feeding tube placement?
a. Post–motor vehicle accident victim with a broken nose and jaw
b. Patient with a bleeding ulcer and possible esophageal varices
c. Elderly patient with a diagnosis of failure to thrive and an inability to chew
d. Patient with an esophageal tumor
ANS: C
Enteral nutrition, commonly called tube feeding, is the administration of nutrients through the gastrointestinal tract when a patient cannot ingest, chew, or swallow, but can digest and absorb nutrients. Nasoenteric tubes are contraindicated in patients with facial trauma, prolonged bleeding, and upper gastrointestinal (GI) blockage (as is seen in cases of solid cancer).
The nurse has just inserted a nasogastric (NG) feeding tube into a patient. What should the nurse do to definitely ascertain that the tube is in the stomach or in the intestine?
a. Test the pH of the contents.
b. Use a carbon dioxide sensor.
c. Lower the head of the bed to 15 degrees.
d. Obtain an order for a chest radiograph.
ANS: D
The most reliable method of feeding tube verification is a chest radiograph (chest x-ray). Gastric and intestinal pH measurements have been shown to differentiate tube placement, with the stomach having a lower pH than the intestines. This helps to ensure that the tube is beyond the pylorus, theoretically reducing the risk for aspiration. This method is helpful before and after radiological confirmation. Carbon dioxide sensors are helpful in determining tube placement between the stomach and the lung. A small plastic piece with an embedded yellow sensor is attached to the end of the feeding tube; the sensor changes color when carbon dioxide is present. Investigators have shown that this reduces the incidence of inadvertent pulmonary placement. This method is helpful before and after radiological confirmation. Elevation of the head of the bed to a minimum of 30 degrees is a simple method used to keep the risk for aspiration at a minimum. The nurse is instrumental in achieving this goal. This method does not ascertain placement but may be useful in preventing aspiration.
The nurse is checking gastric residual on a patient who has a continuously running tube feeding. She finds that the patient has a 600-mL residual volume. How should the nurse respond?
a. Stop the tube feeding.
b. Slow the tube feeding.
c. Continue the tube feeding at the same rate.
d. Increase the rate of the tube feeding.
ANS: A
Tube feedings are stopped if the patient has high gastric residual (more than 500 mL).
Before insertion of a nasogastric (NG) tube, of which finding should the physician be notified?
a. Patent nares
b. Absent bowel sounds
c. Evident gag reflex
d. Impaired swallowing
ANS: B
Absent bowel sounds may indicate decreased or absent peristalsis and increased risk for aspiration. A finding of patent nares rules out obstruction or irritated nares, septal defect, or facial fracture and does not need to be reported to the physician because it is a “normal” finding. The nurse should assess the patient for a gag reflex to determine the patient’s ability to swallow and to discern whether a greater risk for aspiration exists. An evident gag reflex is a normal finding and does not need to be reported to the physician. Impaired swallowing is the probable reason for insertion of the NG tube.
An appropriate technique for nasogastric (NG) tube insertion is for the nurse to:
a. position the patient supine.
b. apply oil-based lubricant to the plastic tube.
c. advance the tube while the patient swallows.
d. measure the tube length from the nose to the sternum.
ANS: C
Encourage the patient to swallow by giving small sips of water or ice chips. Advance the tube as the patient swallows. Rotate the tube 180 degrees while inserting. Swallowing facilitates passage of the tube past the oropharynx. Position the patient sitting with the head of the bed elevated at least 30 degrees. If the patient is comatose, place him in semi-Fowler’s position with the head propped forward using a pillow. If the patient is forced to lie supine, place him in reverse Trendelenburg’s position. This reduces the risk for pulmonary aspiration in the event that the patient should vomit. Apply water-soluble lubricant. The tip of the tube must reach the stomach. Measure the distance from the tip of the nose to the earlobe to the xiphoid process of the sternum. Add 20 to 30 cm (8 to 12 inches) for a nasoenteric tube.
Which technique is appropriate for the nurse to implement during nasogastric (NG) tube insertion?
a. Use sterile gloves.
b. Have the patient mouth-breathe.
c. Advance the tube quickly when the patient coughs.
d. Bend the patient’s head backward after the tube is through the nasopharynx.
ANS: B
Emphasize the need to mouth-breathe and swallow during the procedure. This facilitates passage of the tube and alleviates the patient’s fears during the procedure. Put on clean gloves. Do not force the tube. If resistance is met, or if the patient starts to cough or choke, or becomes cyanotic, stop advancing the tube, pull the tube back, and start over. Have the patient flex his head toward his chest after the tube has passed through the nasopharynx. This closes off the glottis and reduces the risk that the tube may enter the trachea.
The nurse has inserted a nasogastric (NG) feeding tube. The feeding tube has a stylet in place to aid insertion. What should the nurse do once the tube is in place?
a. Remove the stylet immediately.
b. Reinsert the stylet if the radiograph determines incorrect placement.
c. Fasten the end of the NG tube to the patient’s gown using tape and a safety pin.
d. Leave the stylet in place and obtain a chest/abdomen radiograph.
ANS: D
Leave the stylet in place (if used) until correct position has been verified by x-ray film. Never attempt to reinsert a partially or fully removed stylet while the feeding tube is in place. This can cause perforation of the tube and can injure the patient. Do not use safety pins to pin the tube to the patient’s gown. Safety pins become unfastened and can cause injury to the patient.
The nurse is caring for a patient who is receiving continuous tube feedings. What must the nurse do to care for this patient?
a. Verify tube position every 4 to 6 hours.
b. Obtain a radiograph every 4 to 12 hours.
c. Instill air into the stomach via the tube and listen for bubbles.
d. Do not worry about tube placement because the tube has already been determined to be in the right place.
ANS: A
After initial radiographic verification that a tube is positioned in the desired site (either the stomach or the small intestine), the nurse is responsible for ensuring that the tube has remained in the intended position before administering formula or medications through the tube. Therefore, the nurse must verify tube position every 4 to 6 hours and as needed. Because it is not practical to do radiographic checks at this frequency, other methods of determining placement have been investigated. Insufflation of air into the tube while the abdomen is auscultated is not a reliable means of determining the position of the feeding tube tip. It is possible for the tip of a feeding tube to move into a different location (from the stomach to the intestine, or from the intestine into the stomach) without any external evidence that the tube has moved. The risk for aspiration of regurgitated gastric contents into the respiratory tract increases when the tip of the tube accidentally dislocates upward into the esophagus.
The home health nurse evaluates the provision of intermittent tube feedings by the patient’s family member. The nurse notes that additional teaching is required when she notices that the family member:
a. keeps the formula refrigerated between feedings.
b. keeps the feeding tube capped between feedings.
c. begins the feeding before checking tube placement.
d. irrigates the tube with 30 to 60 mL of water before and after feedings.
ANS: C
For intermittent tube-fed patients, test placement immediately before each feeding and before each administration of medication. Each administration of feeding/medication can lead to aspiration if the tube is displaced. For intermittent feeding, have a syringe ready and be sure that the formula is at room temperature. When tube feedings are not being administered, cap or clamp the proximal end of the feeding tube. Draw up in the syringe 30 mL of normal saline or tap water. This amount of solution will flush the length of the tube.
Which evaluation indicates that placement of a nasogastric or enteric tube is correct?
a. Nasointestinal aspirate with a pH of less than 6
b. Pleural fluid pH of less than 6
c. Gastric aspirate with a pH of 5 or less after patient fasting
d. Gastric aspirate with a pH of 4 and continuous tube feedings
ANS: C
Gastric fluid from a patient who has fasted for at least 4 hours usually has a pH of 5 or less.
Fluid from an enteric tube of a fasting patient usually has a pH greater than 6. The pH of pleural fluid from the tracheobronchial tree is generally greater than 6. Patients with continuous tube feeding may have a pH of 5 or greater.
The nurse is checking the residual volume on a patient who is getting intermittent tube feedings via his NG tube. Which of the following may indicate that the patient has started to bleed again?
a. The nurse obtains brown aspirate.
b. The nurse notices that the abdomen is distended.
c. The nurse obtains red aspirate.
d. The nurse notices severe respiratory distress.
ANS: C
Red or brown coloring (coffee-grounds appearance) of fluid aspirated from a feeding tube indicates new blood or old blood, respectively, in the gastrointestinal tract. If the color is not related to medications recently administered, notify the physician. Abdominal distention usually indicates that the tube feeding is not progressing through the GI tract. This could be a sign of paralytic ileus. Stop the tube feeding and notify the physician. If the patient develops severe respiratory distress (e.g., dyspnea, decreased oxygen saturation, increased pulse rate), this may be a result of aspiration or tube displacement into the lung. Stop any enteral feedings. Notify the physician. Obtain chest radiographs as ordered.
The nurse determines that a nasogastric (NG) tube needs irrigation when she:
a. obtains more than 200 mL of residual volume.
b. obtains a small amount of thin watery residual.
c. does not encounter resistance when aspirating the residual.
d. obtains a unusually thick secretions.
ANS: D
Thick secretions indicate the need to irrigate the tube. Note the ease with which tube feeding infuses through the tubing. Excess volume of secretions (more than 200 mL) indicates delayed gastric emptying. Irrigating the NG tube will not help. Failure of the formula to infuse as desired may indicate a developing obstruction.
What is an appropriate amount of nasogastric irrigant for an adult patient?
a. 1 or 2 mL
b. 30 mL
c. 5 to 15 mL
d. 250 mL
ANS: B
Draw up 30 mL of normal saline or tap water in a syringe. This amount of solution will flush the length of the tube. Irrigation of a tube requires a smaller volume of solution in children: 1 to 2 mL for small tubes to 5 to 15 mL or more for large ones.
Which technique is appropriate for providing intermittent tube feeding once placement of the tube has been checked?
a. Cooling the formula
b. Lowering the head of the bed
c. Allowing the bag to empty gradually over 30 to 45 minutes
d. Adding food coloring to detect aspiration
ANS: C
Allow the bag to empty gradually over 30 to 45 minutes. Gradual emptying of tube feeding by gravity from the feeding bag reduces the risk for abdominal discomfort, vomiting, or diarrhea induced by bolus or too-rapid infusion of tube feedings. Cold formula causes gastric cramping. Place the patient in high-Fowler’s position, or elevate the head of the bed at least 30 degrees to prevent aspiration. Do not add food coloring or dye to formula to assist in detecting aspiration, presumably by staining tracheobronchial secretions. This is associated with increased risk for contamination and may cause patient deaths
The nurse is preparing to administer an enteral feeding for the patient. The patient has been on enteral feedings for 2 days. The nurse knows that the most appropriate technique for implementing enteral feeding is:
a. weighing the patient weekly.
b. measuring the gastric residual every hour.
c. changing the formula every 12 hours in an open system.
d. leaving the formula in place in an open system for up to 24 hours.
ANS: C
Maximum hang time for formula is 12 hours in an open system, and 24 to 48 hours in a closed, ready-to-hang system (if it remains closed). Weigh the patient daily until the maximum administration rate is reached and maintained for 24 hours, and then weigh the patient 3 times per week. Check the gastric residual volume. Residual volume should be assessed before each feeding for intermittent feedings.
