enteral tubes Flashcards
enteral tubes
aka gastric tubes
tubes that can be placed in the GI tract when a patient is unable to ingest food, but is still able to digest food and absorb nutrients.
parental nutrition vs enteral tubes
with parental nutrition the patient is unable to ingest, digest, and absorb nutrients.
why would we insert an enteral tube?
- gavage
- decompression
- compression
- lavage
- diagnostic
Gavage
- giving food or medications through a tube when a patient cannot swallow but they have normal bowel fxn.
- preferred over perantal nutrition because is utilizes bowel fxn.
- the tube allows for administration of medication and nutrients throught the GI tract.
Decompression
- the means to remove gas (air), acidic secretions or other substances through the stomach by a prescribed amount of suction applied to the tube.
- relives nausea and vomiting, gaseous abd distention, and helps prevent aspiration.
- indications: an intestinal obstruction (illeus) a temporarilly paralyzed section of the bowel; a cancerous tumor which is ong term
- a person who has undergone surgery and anesthesia and their bowel has not yet recovered (paralytic illeus)
- -
- places pt at risk for electrolyte depletion
compression
- pressure applied by a nasal gastric tube and an inflated balloon to stop bleeding in the esophageal or gastric area
- esophageal varacies (large bleeding pockets of tissue or ulcers)
- ice saline and pressure is applied with a memometer
adds pressure to stop bleeding
lavage
- to wash out stomach contents
- bolus of normal saline that is later suctioned back out
- indication ( ingestion of a posionus substance) to help with the acidity and the erosion it may cause within the GI tract.
diagnostic
evaluate a patients swallowing or gastric ph
gastric tube locations
- nasogastric (NG tube)
- nasoduodenal
- jejunostomy (J tube)
- gastrostomy tube (PEG tube or G tube)
nasogastric (NG tube)
- enters the nose and passes down until the stomach
nasoduodenal
- enters the nose and passes the stomach into the intestine until the duodenum
nasointestinal tube
enters through the nose and teminates down in the intestine
- pnemonia patients, gerd, copd, asthma, breathing diffulculties, or regurgetates a lot
orogastrict tube
enteres through the mouth and terminates in the stomach
- for patients with a contraindication of a tube entering through the nasal cavity
- if they have had nasal or facial trauma
jejunostomy ( J tube)
surgical incision made into the intestine
- used for long term feedings
Gastrostomy tube (PEG tube) (G tube)
surgically making an incision at the stomach to insert a tube
- used for long term feedings
contraindications of tubes
absolute
- facial trauma:
- esophageal trauma
- cranial trauma: thin fragile bones = high risk for bleeding
- birth defects = cleft lip/palate (pediatrics)
- surgery: dont want to compramise a pts airway and to risk the tube percing the thin fragile bones of the face or the cranial cavity
relative
- coagulation abnormalities: pts on heparin or warfarin (PT or pTT is elevated) monitor coagulation panels, platelets, CBC before insertion
- esophageal varices or strictures: depending on severity
- ingestion of alkaline substances:
inserting a tube can cause bleeding as it enters into sensitive, thin tissue cavites and can cause abrasions and scarring
when inserting an NG tube it inhibits the cardio esophageal sphinchter from closing completely and cause reflux of the alaline substance
the three major tubes
- salem sump
- levine
- dobhoff
nasogastric tube (NGT, NG Tube)
- Measured by French System: A system used to indicate the outer diameter of catheters (small number = small diameter)
- Short term use (feeding, decompressing or lavage)
- Neonates: 4-8 Fr
- Pediatrics: 6-14 Fr (21-39 inches in length)
- **Adults: 12-18 Fr (42-55 inches in length)
**
- short term use: 1-2 weeks; 14 days maximum
- use the smallest tube intended for the purpose
salem sump
- double lumen large bore tube
main lumen: containe islets that allows the contents in and out - air vent: (blue pigtail) prevents the suctioning of gastric mucousa from entering into the islets by letting in atmospheric pressure to prevent the adherence of the tube to the gastric wall.
- when connected to suction (80-120 mmHg) the airvent allows for free flowing continous drainage of secretions
- never irrigate the pigtail, insert fluids other than air
- air (20 mL) may only be inserted into the pigtail to irrigate and check patency
- keep the (blue pigtail) above the abdomen at all times to prevent reflux of gastric secretions or contents
- uses: decompression, feeding, lavage, medication administration
- pt may experience burning sensation as it is inserted as the tube is large and rigid
- check patients nares daily q shift for inflamation, blistering - monitor patient for electrolyte depletion because when removing gastric secretions you remove everything
- s/s or electrolyte depletion: hypokalemia, hypomagnesia, hyponatremia
levine
- single lumen tube
- uses: short-term feeding (1-14 days), medication administration
- wall suction: 40-80 mmHg
- flush: warm water
- high risk for migration and cause aspiration; monitor for s/s of migration
dobhoff
- small bore tube
- uses: short-term feeding (1-14 days), liquid medication administration
- tube is to small for medication administration that needs to be crushed because it will clog, need liquid form of medication for tube
- guidewire: aids in insertion, after x-ray confirmation it is removed and is never reinserted. (high risk for pulmonary and/or esophageal punture)
- tungsten weighted
- flush: warm water
- intestine placed: physican using xray
- stomach: nurse or physician
nasointestinal, post pyloris
non-nasogastric tubes
Gastrostomy Tube (PEG Tube, G-Tube)
- placed in the stomach
Jejunostomy Tube
- placed in the intestines
- long tem use (greater than 4 weeks)
uses: long term bowel rest, tube feeding, med administrations, pts who had a stroke
placed using light source during surgery
contraindications: pt with facial trauma fragmentation, trauma to the skull, swallowing issues (high risk for pulmonary aspiration)
monitor the skin: keep clean and dry
small amount of bleeding is normal right after insertion
clean with warm, soapy water and cover it with gauze
placement depends on:
- purpose
- duration
- patient condition
minor complications
- nasal irritation
d/t insertion process and placement of a foreign object - epistaxis (bleeding from the nose)
d/t break of the mucousa - sinusitis
d/t placement irritation in the nose over a period of time
major / placement related complications
- Pneumothorax
d/t a punture from the tube to the lung (dobhoff) - Tracheobronchial aspiration
d/t migration of the tube upwards (levine) - Pneumonia
d/t aspiration of contents - Intracranial Intubation
d/t insertion of any NG tube - Trauma (Nares, larynx, esophagus, mucosal lining)
d/t aggrivation of the areas - DEATH!!
-d/t puntured cranium, lung or misplacement of the tube
alway check coag panels
esp if on blood thinner
pt ptt cbc hemaglobin, electrolytes
sys of infection
alway check coag panels
esp if on blood thinner
pt ptt cbc hemaglobin, electrolytes
sys of infection
inserting a nasogastric tube:
1. provider oder
2. labs
- pt, pTT, CBC, platelets, electrolytes
3. patient assessment
- auscutate bowel sounds; short term feedings and no bowel sounds contact hcp, decompression and no bowel sounds is normal
- check patency of nares and mouth for swallowing and gag reflex
4. education
5. collection of proper equipment
6. cxr post procedure if inserted blindly
equipment needed
- gloves
- tube
- piston syringe (60 mL)
- water soluble lubricating jelly; NO OIL BASED
- pen light
- tape
- marker
- emesis basin
- pH strips
- cup of water
- benzoin, helps tape adhere to the nose
- pulse ox
if pt is npo, have them swallow during insertion instead of siping water
lopez valve
three way stop connecter for feeding
NGT insertion steps
- Educate Patient
why its being placed, the procedure is irritating, instruct to breathe out of mouth - Perform Abdominal Assessment
- Inspect Nares for patency
- Inspect oropharynx
- Gather supplies
- Position Patient High Fowlers
minimum 45 degrees
comatose pt or dec. LOC get extra help
if contraindicated to raise the HOB, place the entire bed in trendelenburg - Measure for NGT insertion length
- Prepare equipment
- Insert tube
- Secure tube
cheking for the mark and make sure to document the lenght it was inserted - Assess PH confirmation
- Send for X-ray Confirmation
measuring an NGT
tip of pt nose
earlobe
xiphoid process
mark tube at where it terminates at the xiphoid process with a marker or tape
NGT insertion
- downward toward the angle of the ear lobe
- roate the tube 180 degrees until it reaches the desired length
helps to avoid percing the fragile bones in the skull
what should the nurse do if the pt begins to cough, gag or O2 levels drop during an NGT insertion?
pull the NGT back slightly into the posterior nasopharx until the s/s subsides then continue to slowly insert the tube.
if the pt continues to exhibit the signs then pull out and stop the procedure.
offer water to help make the swallowing motion to ease insertion
assesing pH confirmation
pH less than five
fasting for four hours: 1- 3
a ph greater than five means it could be in the intestine (pH of 6-9) or in the lung (pH 8-11)
tube feedings and/or medications such as proton pump inhibitors can alter the pH and shouldnt be used to asses the patient
taping the tube
- place the intact half of the tape strip over the bridge of the patients nose
- wrap one end of the slip portion of the strip around the NGT
- wrap the remaining end of tape strip around the NGT in the opposite direction
- place a tape strip over the bridge of the patients nose horizontally
gold standard for NGT insertion
- Radiographic Confirmation
- Note length of tube (exit point), check q shift
- Assess gastric pH
- Air inject and auscultation IS NOT RECOMMENDED to check placement of the tube
- Routine Irrigation is recommended (30 mL or sterile water or sterile saline q 4-6 h)
- Keep HOB elevated 30 degrees or higher
- the piston syringe and irrigants must be changed every 24 hours
- room temperature irrigants reduce GI cramping
recording and reporting
- Record type and size of tube placed, location of distal tip of tube, patient’s tolerance of procedure, condition of naris, and confirmation of tube position by x-ray film examination
- Record removal of tube and patient’s tolerance
- Report any type of unexpected outcome and the interventions performed
entral tube removal
- Assess patient
- Educate patient
- Turn off suction/disconnect if applicable
- Inject tube with 20 mL air to remove contents from tube
- Remove tape from tube/nose
- Drape patient
- Have patient hold breath
- Remove tube steadily and smoothly
- Inspect nose and document
patient HOB should be at a 45 degree angle for removal
pt should be holding their breath when removing the tube
asses for swallowing, intact gag reflex and bowel sounds
considerations
Teaching
- Offer oral hygiene frequently
brushing teeth, ice chips, chapstick
- Report any problems with the tube
ex: pain, movement of the tube, skin deteriation
Pediatric
- Sizing gastric tube
- measure (neonate): tip of the nose, earlobe, umbilicus
- X-ray confirmation
- Observe for vagal stimulation in infants using pulse ox
Gerontological
- Ensure adequate lubrication
Home care
- Assess patient’s/caregiver’s ability
- Assess environment for safety and sanitation
- Teach assessment of tube placement
- Teach how to secure feeding tube and routine care to reduce pressure ulcers
NURSING CONSIDERATIONS
- Assessment GI/Respiratory/Skin
- Monitor Suction (80-120 mm Hg) Continuous/Intermittent
- Intake and Output
- Review Labs
- Note Color and Consistency of Drainage in tube
- Verify Tube Placement
- HOB 30-45 degrees
bright red or coffee color drainage is abnormal
Verifying Feeding Tube Placement
- Monitor the external length of the tube
- Test the pH of the aspirate
- Obtain repeat x-ray confirmation if there is any doubt
Delegation and Collaboration
- Verification of tube placement cannot be delegated to NAP
With regard to tube placement, what observations does the nurse direct NAP to report?
