Week 11- Insertion of NG tube for feeding Flashcards

Question

What do you record/ report?

Answer 1

Record and report type and size of tube placed, location of distal tip of tube, patient’s tolerance of procedure, 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. Tube removal: record patient’s level of comfort.

Answer 2

* Instruct patient or family caregiver to offer oral hygiene frequently and keep patient’s lips lubricated. * Teach patient or family caregiver to report tension on feeding tube or displacement of tape or tube fixation device; instruct patient or caregiver to stabilize the tube and call for help.

Answer 3

The distance from nose-to-ear-to–mid-umbilicus better predicts insertion length for gastric tube placement in neonates and children than traditional nose-to-ear-to-xyphoid measurements X-ray film confirmation of tube position is not routinely per- formed because of the radiation risk. • Routine flushing of tubes is not recommended in pediatric patients. • When inserting a feeding tube in an infant, observe for vagal stimulation evidenced by a decreased heart rate.

Answer 4

Nurses insert small-bore feeding tubes nasally for intermittent or continuous feeding. It is possible for the tip of a feeding tube to move or migrate into a different location (e.g., from the stomach into the intestine or esophagus, from the intestine into the stomach). Although all tubes should be marked to document correct position, tube dislocation can sometimes occur without any external evidence that the tube has moved. The risk of aspiration of regurgitated gastric contents into the respiratory tract increases when the tip of the tube accidentally dislocates upward into the esophagus. Following initial x-ray film verification of correct feeding tube position, you must monitor the tube to ensure that the tube tip remains in the intended site. Based on a patient’s clinical condition and agency policies, you check feeding tube position at regular intervals (often every 4 to 6 hours) and before administering formula or medications through the tube Monitor the external length of the tube and observe the appearance, volume, and pH of fluid aspirated through it. The color of the fluid can help differentiate gastric from intestinal placement. Because most intestinal aspirates are stained by bile to a distinct yellow color and most gastric aspirates are not, the difference in color can often distinguish the site Testing the pH of an aspirate at the bedside using pH paper offers some information regarding the position of a feeding tube, but results are not reliable during continuous feeding and should be used in combination with other indicators with careful assessment Do not insufflate (blow) air into tube to check placement ** it says not to do this in readings, but on the ppt it says this is a traditional way of checking, and I did see some nurses do this while using a stethoscope).

Answer 5

1  Review agency policy and procedures for frequency and method of checking tube placement. Do not insufflate air into tube to check placement. 2  Observe for signs and symptoms of respiratory distress during feeding: coughing, choking, or reduced oxygen saturation. 3  Identify conditions that increase risk for spontaneous tube migration or dislocation: Altered level of consciousness, agitation. Retching/vomiting/coughing. nasotracheal suctioning ** are they on a gastric acid inhibitor?? This would eliminate usefulness of pH measurements by buffering the pH of stomach

Answer 6

NOTE: i heard from my nurse friends they don't actually do this in clinical. They do the initial x-ray and tube tip is weighted so they've never had it displace. They also said they rarely put any air in bc gastric contents spill out right away when they do. 1  Identify patient using two identifiers (i.e., name and birthday or name and account number) according to agency policy. Compare identifiers with information on patient’s identification bracelet. 2  Prepare equipment at patient’s bedside, perform hand hygiene, and apply clean gloves. 3  Verify tube placement at the following times: a  For intermittently tube-fed patients, test placement immediately before each feeding and before medications. b  Follow agency policy regarding pH testing for patients receiving continuous tube feeding. AACN (2010) recommends that continuous feedings be stopped for several hours to obtain reliable pH readings. c  Wait to verify placement at least 1 hour after medication administration by tube or mouth. 4  Draw up 30 mL of air into a 60-mL syringe and attach to end of feeding tube. Flush tube with 30 mL of air before attempting to aspirate fluid. Repositioning patient from side to side is helpful. In some cases more than one bolus of air is necessary. 5  Draw back on syringe slowly and obtain 5 to 10 mL of gastric aspirate Observe appearance of aspirate (see Fig. 31-2). 6  Gently mix aspirate in syringe. Expel few drops into clean medicine cup. Measure pH of aspirated GI contents by dipping pH strip into fluid or by applying a few drops of fluid to strip. Compare color of strip with color on chart (see illustration) provided by manufacturer. a  Gastric fluid from patient who has fasted for at least 4 hours usually has pH range of 5.0 or less. b  Fluid from tube in small intestine of fasting patient usually has pH greater than 6.0 c Patient with continuous tube feeding may have pH of 5.0 or higher d pH of pleural fluid from tracheobronchial tree is generally greater than 6.0 7  If after repeated attempts it is not possible to aspirate fluid from a tube that was confirmed by x-ray film to be in desired position and if there are no risk factors for tube dislocation, monitor external length of tube and observe patient for evidence of respiratory distress 8  Irrigate tube 9  Remove and dispose of gloves and supplies in appropriate receptacle. Perform hand hygiene.

Answer 7

Curdled enteral formula and improperly crushed medications are the most common causes of feeding tube occlusion

Answer 8

1  Inspect volume, color, and character of gastric aspirates (if obtainable). 2  Assess bowel sounds. 3  Note ease with which tube feeding infuses through tubing. 4  Monitor volume of enteral formula administered during a shift and compare with ordered amount. 5  Refer to agency policies regarding routine irrigation, usually every 4 to 12 hours IMPLEMENTATION 1  Identify patient using two identifiers (i.e., name and birthday or name and account number) according to agency policy. Compare identifiers with information on patient’s identification bracelet. 2  Perform hand hygiene, prepare equipment at patient’s bedside, and apply clean gloves. 3  Verify tube placement (see Skill 31-2) if fluid can be aspirated for pH testing. 4  Irrigate routinely before, between, and after final medication (before feedings are reinstituted); and before an intermittent feeding is administered. 5  Draw up 30 mL of water in syringe (see illustration). Do not use irrigation fluids from bottles that are used on other patients. Patient should have an individual bottle of solution. 6  Change irrigation bottle every 24 hours. Irrigation trays, which hold both irrigation fluid and syringe, are considered open systems and may be more easily contaminated than sterile water bottles. 7  Kink feeding tube while disconnecting it from administration tubing or while removing plug at end of tube (see illustration). 8  Insert tip of syringe into end of feeding tube. Release kink and slowly instill irrigation solution (see illustration). 9  If unable to instill fluid, reposition patient on left side and try again. 10  When water has been instilled, remove syringe. Reinstitute tube feeding or administer medication as ordered. Flush each medication completely through tube (see Skill 21-2). 11  Remove and discard gloves; dispose of supplies in appropriate receptacle. Perform hand hygiene

Answer 9

Administering enteral nutrition: nasoenteric, gastrostomy, jejunostonmy tube ASSESSMENT 1  Assess patient’s clinical status to determine potential need for tube feedings: Decreased level of consciousness, nutritional deficits, head or neck surgery, facial trauma, or impaired swallow. Consult with nutrition support team or health care provider. 2  Assess patient for food allergies. 3  Perform physical assessment of abdomen, including auscultation for bowel sounds before feeding (see Chapter 6). 4  Obtain baseline weight and review serum electrolytes and blood glucose measurement. Assess patient for fluid volume excess or deficit, electrolyte abnormalities, and metabolic abnormalities (e.g., hyperglycemia). 5  Verify health care provider’s order for type of formula, rate, route, and frequency. IMPLEMENTATION 1  Identify patient using two identifiers (i.e., name and birthday or name and account number) according to agency policy. Compare identifiers with information on patient’s identification bracelet. 2  Perform hand hygiene. Apply clean gloves (Bankhead et al., 2009). 3  Obtain formula to administer: a Verify correct formula and check expiration date; note condition of container. b Provide formula at room temperature. 4  Prepare formula for administration: a Use aseptic (clean) technique when manipulating components of feeding system (e.g., formula, administration set, connections). b  Shake formula container well. Clean top of canned formula with alcohol swab before opening it (Bankhead et al., 2009). c  For closed systems, connect administration tubing to container. If using open system, pour formula from brick pack or can into administration bag 5  Open roller clamp and allow administration tubing to fill. Clamp off tubing with roller clamp. Hang container on intravenous (IV) pole. 6  Place patient in high-Fowler’s position or elevate head of bed at least 30 degrees (preferably 45 degrees). For patient forced to remain supine, place in reverse Trendelenburg’s position. (head of bed is higher than feet) 7  Verify tube placement (see Skill 31-2). Observe appearance of aspirate and note pH measure. 8  Check gastric residual volume (GRV) before each feeding (for bolus and intermittent feedings) and every 4 to 6 hours (for continuous feedings) a Draw up 10 to 30 mL air into syringe and connect to end of feeding tube. b  Inject air into tube. Pull back slowly and aspirate total amount of gastric contents (see illustration). c  Return aspirated contents to stomach unless volume exceeds 250 mL (see agency policy) d  Do not administer feeding when a single GRV measurement exceeds 500 mL or when two measurements taken 1 hour apart each exceed 250 mL e  Flush feeding tube with 30 mL water (see Skill 31-3). 9  Before attaching feeding administration set to feeding tube, trace tube to its point of origin. Label administration set, “Tube Feeding Only.” 10  Intermittent gravity drip: a  Pinch proximal end of feeding tube and remove cap. Connect distal end of administration set tubing to feeding tube and release tubing. b  Set rate by adjusting roller clamp on tubing or attach tubing to feeding pump. Allow bag to empty gradually over 30 to 45 minutes (see illustration). Label bag with tube-feeding type, strength, and amount. Include date, time and initials c Change bag every 24 hours 11 Continuous drip method: a  Connect distal end of administration set tubing to feeding tube as in Step 10a. b  Thread tubing through feeding pump; set rate on pump and turn on (see illustration). 12  Advance rate of tube feeding gradually, as ordered. 13  Flush tubing with 30 mL water every 4 hours during continuous feeding (see agency policy), before and after an intermittent feeding. Have registered dietitian recommend total free water requirement per day and obtain health care provider’s order (see Skill 31-3). 14  When patient is receiving intermittent tube feeding, cap or clamp end of feeding tube when not being used. 15  Rinse bag and tubing with warm water whenever feedings are interrupted. Use new administration set every 24 hours. 16  Dispose of supplies and perform hand hygiene EVALUATION 1  Measure GRV per policy, usually every 4 to 6 hours, and ask if nausea or abdominal cramping is present. 2  Monitor intake and output at least every 8 hours and calculate daily totals every 24 hours. 3  Weigh patient daily until maximum administration rate is reached and maintained for 24 hours; then weigh patient 3 times per week. 4  Monitor laboratory values. 5  Observe patient’s respiratory status. 6  Auscultate bowel sounds. 7  For tubes placed through abdominal wall, inspect site for signs of impaired skin integrity.

Answer 10

Nasogastric, orogastric tube feeding Supply adequate nutrition to an infant who is unable to suck, tires easily, cannot swallow or chew Enteral over parenteral Preserve stomach mucosa and decrease risk of infection, infiltration Easy to manage at home Aka gavage feedings Debate over if tube should go in an infants mouth because tube may obstruct nasal passage Infants only breath through nose Most tubes will be inserted through their mouth Orogastric insertion can decrease possibility of striking vagal nerve in the back of throat, causing brady cardia For older children, insertion via nose more comfortable To prevent irritation/ulcer on nose, always tape nasogastric tubes to the child's cheek rather than forehead to secure it in place Tubes are radiopaque= can be confirmed on x-ray Nutrition formula used should be room temp Elevate child upper trunk before feeding 30-40 degrees, semi fowlers So fluid will flow downward to stomach and not up into the esophagus= aspiration To reduce aspiration in infants, place in car seat or hold them upright For small infants, before feeding it is often necessary to aspirate stomach contents to see whether infant is absorbing the quantity of the fluid given as well as confirmation of tube placement After noting the amount and type of fluid aspirated, replace stomach contents so child does not lose electrolytes Attach syringe to the tube and allow formula to flow by gravity into tube Don’t use barrel of syringe to force feeding forward in order to prevent reflux and aspiration Most infants enjoy a soother while eating to mimic the sucking reflux Also helps maintain/strengthen sucking reflux for later when the child returns to oral feedings At end of feeding, flush tube with 1-5 ml of water to clear tube of feeding solution Prevent blockage, maintain patency Keep child's head elevated for 1 hour after feeding to prevent esophageal reflux Provide mouth care at least twice a day to encourage salivation Mouths will become dry and prone to formation of mucosal ulcers

Answer 11

Therapeutic play can be divided into three types: Energy release Dramatic play Creative play

Answer 12

Energy release Release energy by pounding, hitting, running, punching and shouting Help release anxiety Toddlers enjoy pounding pegs with hammers Or pretending to cut wood Give clay to punch and destroy or allow school age child to punch balloon *best for toddlers

Answer 13

Dramatic Play Acting out an anxiety producing emotion Most effective with preschool children because they are at the peak of imagination Use common healthcare equipment Dolls, doll beds, stethoscopes, IV equipment, syringes, masks and gowns Puppets of doctors, nurses, parents and children, help children express their feelings Anatomical correct dolls may help children discuss sexual mistreatment Play with children at the beginning of illness to see if children communicate feelings about illness Play with children during illness to describe procedures Repeat play after any painful or traumatic procedure ex surgery If play sessions reveal fears, play sessions should be scheduled at least once daily Allow play to be nondirective Empowers child Less fearful Watch for unusual use of equipment Ex. Thermometer in dolls eye Requires further patient teaching Ask for clarification if child says something such as "I'm giving an injection to all the bad dolls" This explains how the child perceives injections Do not rush to reassure children because reassurance can infer that the children should not ask any more questions Do not reply on parents to do the patient teaching Ensure you are totally thorough with child Prepare them well for procedure Children over 9 find playing with dolls too childish to be of benefit They enjoy instead to handle syringes, equipment Active handling helps to eliminate fear because it identifies exactly what the child has to face, meets their concrete learning needs *best for school age* preschool

Answer 14

Creative Play Some children are too angry to act out their feelings through dramatic play May be able to draw a picture instead Give child blank paper, and crayons Tell child to draw a picture of themselves May not draw a leg because they think the doctors are amputating the leg Draw a child behind bars: punishment from doctors and nurses Explain that they are not being punished Child may draw a picture involving death Discuss this with child Older children may prefer to make lists of procedures/experiences they like, dislike

Answer 15

``` Confirmation of feeding tubes MUST be verified by Xray and documented by physician Intial insertion Re-insertion Suspected migration Tube displacement greater than 10cm ```

Answer 16

Measurement of tube length Visual assessment of the aspirate Obtain gastric aspirate /PH measurement - What PH do you expect from gastric contents? The pH of gastric aspirate is acidic (1-5) The pH of intestinal aspirate is 6 or higher. The pH respiratory aspirate is 7 or greater

Answer 17

Flush tube through stylet connector (10cc H20) Remove stylet Mark tube at nare exit point Measure external segment of tube (nostril to end of tube) Assess client and commence feeds as ordered

Answer 18

Review the individualized care plan(type of formula, feeding schedule( intermittent /continuous )&rate ) Asses patient and check for placement Client positioning Check the equipment (Pump , jug ,syringe & water) Check the formula kind & expiry Calculate the rate according to the care plan and perform the proper checks Explain procedure and what is expected for patient / family Be aware of the Residual checks and when holding of feeds

Answer 19

General assessment :How is the patient tolerating the feeds? Follow the care plan(intermittent /continuous)and check for residual and tolerance Intake and output Nutritional status Hydration Digestion Kidney function Muscle function Bowel function Medications that may be affecting the nutritional intake Does the dietary régime fulfill the patients needs? Weight changes – monitor gain or loss Administer medications safely Patients positioning head of bed elevated to 30 - 45 degrees Monitor for complications Administer medications safely Patients positioning head of bed elevated to 30 - 45 degrees Monitor for complications ASSESS TUBE PLACEMENT Before each feed Before medication delivery And once a shift If aspiration is suspected the FEED IS STOPPED Suction and assess patient Notify physician

Answer 20

c) stop the feed, then suction and assess, then call the physician

Answer 21

GENERAL RULES: The medications need to be crushed Mixed with small amount of water (30ml) (ppt says 15-30 luke warm water) Flush of water between each medication (15ml) Given individually/separately Liquid form – when possible DO NOT crush sustained /delayed release meds Cytotoxic meds should not be crushed – talk to pharmacy DO NOT mix medications – they can set like cement and clog tube Consult with pharmacy and use a prepared elixir whenever possible

Answer 22

Diarrhea (common) nausea& vomiting , gas/ bloating/cramping , constipation Tube displacement, tube obstruction, residue of medications, nasopharyngeal irritation Fluid Volume& Electrolyte imbalances (mainly deficits) Aspiration pneumonia Tissue damage/Mucous membranes Dehydration and azotemia Metabolic: hyperglycemia & dumping syndrome

Answer 23

WAYS TO PREVENT DUMPING SYNDROME. Slower delivery Room temperature feed Continuous method Advise patient to remain sitting up for an hour after a feed Balance water administered with a feed…maybe too much at one time? Consult with dietitian

Answer 24

Is a potentially fatal complication that occurs when a malnourished patient begins receiving nutrition again . Patients at risk :cancer patients undergoing chemotherapy, malnourished elderly people, homeless or alcoholic patients who haven’t eaten in several days, and anorexia nervosa. During starvation mode, the body’s metabolism reduced and several hormonal and metabolic changes takes place to save energy to maintain body function and fat becomes the main energy source .. Once refeeding begins Formula usually high in protein and carbohydrates which increase glucose level and release of insulin . Insulin causes uptake of glucose ,phosphate ,potassium and magnesium into the cells which lead to: Hypophosphatemia : hypotension ,seizures, anemia and respiratory distress Hypokalemia: delirium , resp distress Hypomagnesaemia :seizures ,anemia ,GI symptoms Arrhythmia ,neuromuscular disturbances ,weakness ,lethargy Refeeding should be started at a low level, monitoring patient closely , lab checks before and during and correction of electrolyte imbalance.