2Out line Define the nasogastric tube Discuss the types of nasogastric tube .List the purpose of using the nasogastric tubeDiscuss insertion nasogastric tubeDiscuss removing nasogastric tubeDiscuss administering a tube feedingDiscuss Irrigating Nasogastric TubeExplain the procedure.List the potential complications of Nasogastric Tube.Demonstrate the procedure.
3IntroductionGastrointestinal intubation is inserting of rubber or plastic tube into the stomach , duodenum or intestinalThe tube inserted through mouth .nose , or abdominal ( gastrostomy .jejunostomy )The tube short , medium , long
4Types of Tubes Short- Nasogastric tube Introduced from the nose to the stomachLevin and Gastric (Salem) SumpUsed to remove gas and fluid from the upper GI tract or to obtain a specimen of gastric contentsSometimes used for medications or feedings ( gavage )
5Levin Tube Single Lumen (hollow part of tube) Size 14-18 French Made of plastic or rubber with opening near tipIt is 125 cm longCircular markings on the tube serve as insertion guides
6Gastric (Salem) Sump Gastric sump tube ( salem. Ventrole) Double lumen catheter .clear plasticPlastic, FR.It is 120 cm longUsed to decompress thestomach, keeps it empty
7Smaller, inner tube (blue pigtail) vents the larger suction-drainage tube to the atmosphere by way of an opening at the distal end of the tube.Keeps the suction force at the drainage openings at less that 25 mm Hg to prevent capillary irritation.Connected to low continuous suction.Vent lumen kept above the client’s waist.
9Medium tubes.Medium length- nasoenteric used for feeding. Example- DobhoffPlaced in the duodenum or jejunum by fluoroscopy (x-ray dept) or at client’s bedside.Verified by x-ray before feedingsbegin. May take up to 24 hrs.to pass through the stomachinto the intestines.Place client on right sideto facilitate passage
10Long- nasoenteric tubes. Long- nasoenteric tubes introduced through the nose and passed through the esophagus and stomach into the intestinal tract.Used to aspirate intestinal contents-ie. gas and fluidUsed to (Decompression) to prevent intestinal obstruction.Due to peristalsis, prevents vomiting, reduces tension at the incision line and prevents obstruction.
11Long- nasoenteric tubes. Examples of long tubes:Miller- Abbott-is double lumen ( fr ) 300 cm rubber tubeone lumen used for aspiration and other for Introduce with mercury, water, or saline
12Long- nasoenteric tubes Harris-Is single lumen ( 14 fr )used for suction and irrigationmercury-weighted of about 180 cmThis tube metal tip that lubricateThis use for irrigation & suction .
13Long- nasoenteric tubes Cantor tube –has a large balloon at distal end of tube. Filled with4- 5 ml of mercury, water or saline to weight the tubeIt is 300 cm long
15Tube inserted through the nose into stomach DefinitionTube inserted through the nose into stomach
16Purposes:To administer tube feedings and medications to clients unable to eat by mouth or swallow a sufficient diet without aspirating food or fluids into the lungsTo establish a means for suctioning stomach contents to prevent gastric distention ,nausea, and vomiting.To remove stomach contents for laboratory analysisTo lavage(wash)the stomach in case of poisoning or overdose of medications.
17Purposes To drain fluid or air from the stomach. To promote healing after bowel surgery.To monitor bleeding in the gastrointestinal (GI) tract.To help treat an intestinal obstruction.
18Assessment & Preparations: Assessment & Prepare the clientPresence of gag reflexMental status or ability to cooperate with procedureCheck physician's order for insertion of NG tube.Explain procedure to patient.Assist the patient to high Fowler's position.Drape chest with disposable pad
19Assess the client nares Ask client to hyperextend the head & using flashlightObserve ( intactness of tissue nostrils including any irritation or abrasion )Examine the patient’s nostril for septal deviation. To determine which nostril is more patent, ask the patient to occlude each nostril and breathe through the otherPatency of nares & intactness of nasal tissue ( note especially history of nasal surgery or deviated septum )
20Assess & prepare the tube If rubber tube :used placed it on ice for 5 to 10 minutesThis stiffens the tube , facilitating insertionIf plastic tubeUsed place it in warm water until tube softer & more flexibility , facilitating insertion
21Equipments: Nasogastric tube Adult - 16-18F Viscous lidocaine 2% Oral analgesic spray (Benzocaine spray or other)Oral syringe, 12 mLGlass of water with a strawWater-based lubricant
22Equipments: Non allergenic adhesive Tape 2,5 cm wide Emesis basin or plastic bagWall suction, set to low intermittent suctionSuction tubing and containerFlashlight .Stethoscope.Toomey syringe (20 to 50 ml) .TissuesDisposable pad & gloves . .Tongue blade .Normal saline solution (for irrigation only).
25NoteA nasogastric (NG) tube is used for the procedure. The placement of an NG tube can be uncomfortable for the patient if the patient is not adequately prepared with anesthesia to the nasal passages and specific instructions on how to cooperate with the operator during the procedure
26Determine how far to insert the tube Measure the distance to insert tube by placing tip of tube at client's nostril and extending to tip of ear lobe and then to tip of xiphoid process.Mark tube with piece of tape.
27Nasogastric tube lubrication with water-based lubricant.
28Estimation of nasogastric tube length from nostril to stomach
29Insert the tube Prepare equipment. Wash hands. Wear disposable gloves. Instill 10 mL of viscous lidocaine 2% (for oral use) down the more patent nostril with the head tilted backwards, and ask the patient to sniff and swallow to anesthetizeLubricate tip of tube with water soluble lubricant.Ask client to lift head, and insert tube into nostril while directing tube upward and backward.
30Aspiration of viscous lidocaine into an oral syringe
32Cont,,If client gag when tube reaches pharynx, provide tissues for tearing or watering of eyes.When pharynx is reached, instruct client to touch chin to chest.Encourage client to sip water through a straw or swallow even if no fluids are permitted.
33Patient flexing his neck and drinking water while a nasogastric tube is inserted.
34Advance tube in downward and backward direction when client swallows. Stop when client breathes.If gagging and coughing persist, check placement of tube with tongue blade and flash light.Keep advancing tube until tape marking is reached.Do not use force, rotate tube if it meets resistance.Discontinue procedure and remove tube if there are signs of distress, such as gasping, coughing, cyanosis, and inability to speak or hum.
35Confirming PlacementTube placement is confirmed prior to any use of the tube for suction, irrigation, medication admin. or feedings.Initially, an x-ray should be ordered to confirm placement of weighted feeding tubes (Dobhoff).Verify NG or Salem Sump tubes by auscultation of an injected air bolus over the epigastrium or aspirate stomach contents.Measurement of tube length, visual inspection and measuring of the aspirate pH is also recommended.
38Securing the GI tube Use a skin barrier to prep the skin Use NG strip or place a piece of tape under the tube at the nose and secure to the skin, place another piece of tape over the first piece.Secure tube to client’s gown with a safety pin.
40Document Document: Tube type and size Drainage or aspirate (residuals) amount, color and consistencyIrrigation type and amountSuction- type and level (i.e. low intermittent)Feeding- type and amountPatient tolerancePatient/ Family education and response
41NG SuctionTube for decompression will be attached to Intermittent Suction- keep suction between 20-80mm Hg.Continuous suction greater than 25mm Hg can cause damage to the gastric mucosa.Do not clamp or plug the vent lumen.A soft hissing sound will be heard from the vent lumen if it’s patent.Record amt. on I&O.
42Conte,,, Remove disposable gloves. Wash hands. Remove all equipment. Keep the client at comfortable position.Assist with or provide oral hygiene at regular intervals.
43Complications The main complications of NG tube insertion :- aspiration and tissue trauma.Placement of the catheter can induce gagging or vomiting, Patient discomfortEpistaxisPulmonary complicationEsophageal perforation
44Contraindications Absolute contraindications Severe mid face traumaRecent nasal surgeryRelative contraindicationsCoagulation abnormalityEsophageal varicose or strictureAlkaline ingestion
46Tube Feedings Meet nutritional needs when oral intake not possible Advantageous over TPNGI integrity is preservedNormal insulin/glucagon ratios are maintainedAdmin. intermittent, continuousAccessed by nasogastric, nasoenteric, gastrostomy or jejunostomy tube
48AssessmentBefore a nasogastric or orogastric feeding determine type amount frequency of feeding & tolerance of previous feedingAssessment signs of malnutrion or dehydrationAssess allergies to any foodPresence bowel soundAny tolerance of previous feeding ( delayed gastric empty , abdominal distention . Constipation )
49To restore or maintain nutritional status. To administer medications. Purposes:To restore or maintain nutritional status.To administer medications.
50Equipments: Feeding container. Large syringe with plunger or calibrated plastic feeding bag with tubing or Prefilled bottle with a drip chamber tubing & flow regulator clampStethoscope. Disposable gloves. Alcohol swab.Toomey syringe 20 to 50 ml with adaptor .Water for irrigation or normal saline.Emesis basinFeeding pump as required
52Explain procedure to client. Prepare equipment. Preparation:Explain procedure to client.Prepare equipment.Check amount, concentration, type, and frequency of tube feeding on client's chart.Check expiration date of formula
53Procedure Use stethoscope to assess bowel sounds. Wash hands. Wear disposable gloves.Position client with head of bed elevated at least 30 degrees or as near normal position for eating as possible. Fowlers position
54Performance:Check to see that the NG tube is properly located in the stomach.Flush tube with 30 ml of water for irrigation.Disconnect syringe from tubing.Warm feeding to room temperatureAssess residual feeding contentAspirate all stomach content & measure a mount prior to administering the feeding
55Feeding bag Open system ) ) Cleanse top of feeding container with alcohol before opening it.Pour formula into feeding bag and allow solution to run through tubing.Close clamp.Attach feeding setup to feeding tube.Open clamp.Regulate drip according to physician's order, or allow feeding to run in over 30 minutes.
56Feeding bag Open system ) ) Add 30 to 60 ml of water for irrigation to feeding bag when feeding is almost completed and allow it to run through the tube.Clamp tubing immediately after water has been instilled. Disconnect from feeding tube.Clamp tube and cover end.
57Open system ) ) Syringe feeding Remove plunger from 30- or 60-ml syringe.Open clamp.Attach syringe to feeding tube.Pour amount of tube feeding into syringe.Allow food to enter tube.Regulate rate, by height of the syringe. Do not push formula with syringe plunger.When syringe has emptied, hold syringe high.
58Syringe feedingAdd 30 to 60 ml of water for irrigation to syringe when feeding is almost completed, and allow it to run through the tube.Clamp tube .Disconnect from tubeCover end of tube.Observe the client's response during and after tube feeding.Keep client in upright position forat least 30 minutes to 1 hour after feeding.Remove gloves. Wash hands
59Documentation:Record type and amount of feeding, residual amount ,and client's response, monitor blood glucose level, if ordered by physician.
64Preparation: Check physician's order for irrigation. Explain procedure to client.Prepare necessary equipment.Check expiration dates on irrigating solution.Wash hands.Wear disposable gloves.Assist client to semi-Fowler's position.Check placement of NG tube.Pour irrigating solution into container.Draw up 30 ml of saline solution.Place tip of syringe in tube.
65Hold syringe upright and gently insert the irrigate or allow solution to flow in by gravity. Do not force solution into tube.If unable to irrigate tube, reposition patient and attempt irrigation again.Withdraw or aspirate fluid into syringe.If no return, inject 10 to 20 cc of air and aspirate again.Measure and record amount and description of irrigant and returned solution.Remove equipment& gloves.Wash hands.
66Documentation:Record irrigation procedure, description of drainage, and client's response.
68Purposes: To provide as much comfort as possible for the client. The physician will order the tube to be removed carefully, when the NG tube is no longer necessary for treatment:To provide as much comfort as possible for the client.To prevent complications.
69Equipments: Tissues. 50-ml syringe (optional). Disposable gloves. Disposable plastic bag.Disposable pad.Normal saline solution or water for irrigation (optional).Emesis basin.
71Preparation: Check physician's order for removal of NG tube. Explain procedure to client.Assist to semi- Fowler's position.Prepare equipment.Wash hands.Wear clean disposable gloves.Place disposable pad across client's chest.Give emesis basin and tissues to client.Attach syringe and flush with 10 ml of water or normal saline solution.
72Carefully remove adhesive tape from client's nose. Instruct client to take a deep breath and hold it. Clamp tube with fingers by doubling tube on itself.Quickly and carefully remove tube while client holds breath.Dispose of tube.Remove gloves and place in bag.Clean and dry face, nose and mouth.Remove all equipment and dispose of according to agency policy.& Wash hands.
74Definition of Parenteral Nutrition The administration of complete and balanced nutrition by intravenous infusion in order to support anabolism, body weight maintenance or gain, and nitrogen balance, when oral or enteral nutrition are not feasible or are inadequate
75Indications for TPNMall absorption syndromes, such as short bowel syndromeConditions requiring complete bowel rest for prolonged periodsPre and post-operative support in patients with pre-existing malnutrition, in who GI function is impairedMalignancy undergoing treatment, surgery, radiation, chemo who are unable to obtain adequate nutrition by an enteral route
76TPN is generally NOT indicated… When an inpatient has a functioning GI tractTPN therapy is expected to be less than 5 daysPrognosis does not warrant aggressive nutrition support
77Source of Nutrition Eternal nutrition Parenteral nutrition Central parenteral nutrition (CPN=TPN)Peripheral parenteral nutrition (PPN)Long-term home parenteralnutrition (HPN)
78Clinical decision algorithm route of nutrition support Nutrition AssessmentDecision to institute special nutrition supportYESFunctional GI TractNOEnteral NutritionParenteral NutritionShort-term:NG, ND,NJLong-term:Gastrostomy JejunostomyGI functionPPNTPNIntactNutrientsDefinedFormulaGI function returnAdequateInadequateAdequateYESNOPNOral Feeding