1. Bowel Elimination Pgs 684-702 & Chapter 29 G.I. Intubation
Nursing Fundamentals
Bowel Elimination
Pgs
&
Chapter 29 G.I. Intubation

2. Measures to promote bowel elimination
Nurses use 2 interventions:
1. Suppositories
2. enemas

3. Suppository
Oval or cone shaped mass of medication that melts at body temperature

4. Local effects of suppositories
LOCAL EFFECTS – include administering the suppository and it lubricating and softening dry stool. The supp. Irritates the wall of the rectum and anal canal and stimulates smooth muscle contraction to increase rectal distention and increasing the urge to defecate

5. Systemic Effects of Suppositories
Systemic Effects - These are taken by mouth where they work internally to increase motor activity in the G.I. Tract to cause defecation

6. Administering Enemas
An enema introduces a solution into the rectum to:
Cleanse the lower bowel (most common use)
To soften feces
To expel flatus
To sooth irritated mucous membranes
To outline the colon during diagnostic x-rays
To treat worm and parasite infestations (anti-helminth – remember in ch 5 Disease?)

7. Cleansing Enemas
Are used to cleanse the lower bowel before a procedure or surgery or for constipation
With a cleansing enema, defecation should occur within minutes after administration

8. Cleansing Enemas
Usually involves large volumes of liquid entering the lower bowel causing distention or cramping
Nurse must administer these slowly as to not rupture the bowel

9. Types of cleansing enemas
Tap water and normal saline enemas
Soap solution enema
Hypertonic saline enema
Keep these in for minutes, then expel

10. Types of retaining enemas
Sometimes oil enemas
Always foam enemas like the steroid types
Keep these in for 30 minutes then expel except the foam enemas usually dissolve in the instestin and nothing comes out

11. Tap Water and Normal Saline Enema
These are preferred due to the less amount of irritation that these have
Tap water and saline enemas have the same degree of effectiveness for cleansing the bowel

12. Problems with Tap water enemas
Because tap water is hypotonic, fluid is absorbed through the bowel. If several enemas are given, fluid and electrolyte imbalances can occur.
ONLY 3 ENEMAS CAN BE GIVEN AT A TIME to prevent this fluid imbalance from occurring

13. Soap Suds enema
Usually 1 packet of soap is combined with up to 1000ml of water. If concentrations are not correct and solution is too concentrated, it will cause irritation to the rectum

14. Hypertonic Saline Solutions
These use sodium phosphate as their main ingredient
This is a FLEETS enema, when given, it draws water into the colon to aid in defecation. The pts output will be more than what was instilled. This too, is a rectal irritant
Solutions such as FLEETS can be purchased OTC and in 4oz increments

15. Retention Enemas
These include solutions usually made of oil or steroids.
Pt is to retain or hold the solution for at least 30 minutes and some retention enemas are not expelled at all
Oil filled enemas come pre-filled and can be bought OTC also, these oil enemas lubricate and soften the stool for easier expulsion

19. EQUIPMENT NEEDED Always have gloves (non-sterile)
Lubrication (surgi-lube) in individ. Packets
Chux pads
Bed pan or bedside commode
The ordered enema bottle, or kit for soap suds enema

20. When NOT to administer an enema
Never perform this technique while pt is sitting on toilet, too difficult to administer
Never to be used daily, pt will rely on this to stool, bad
Never administer with N/V or abdominal pain d/t possibility of perforating intestine

21. Ostomy An ostomy is a surgically created opening into a body structure
Some patients have had surgery to repair or remove part or most of their intestines
Once surgery has taken place, the intestine needs to recover (in many cases)

22. A ulcerated intestine can be removed and either reconnected (anastamosis) or the working portion of the intestine is pulled through the abdominal wall and stitched there. The other end is left just inside the abdominal wall to rest. An opening is created in the inner abd. wall and the working end of the intestine is pulled through to the outside
You now have an ostomy and that ostomy must collect into a bag

23. Ostomy Care
See page 687 in book for pictures of stomas and their locations
Persons with a stoma wear an appliance which is a bag or collection device over the stoma
Many patients can care for this themselves however, nurses can also care for stomas

24. What to assess
Check the condition of the skin around the actual stoma for redness or excoriation
The stoma itself should be beefy red and look like organ meat, no blood should be present, if so, notify RN or Dr.immediately
Stoma should not be cyanotic, call Dr. STAT

25. Providing peristomal care
Preventing skin breakdown is a major challenge of ostomy care
Enzymes in stool can quickly excoriate the skin. Excoriation is a chemical injury of the skin, if not properly cared for, infection will occur

26. Washing
Washing the actual stoma and skin around the stoma with mild soap and water and patting it dry will preserve the skin
Companies also make special skin care pastes to be used in peristomal care

27. Applying the ostomy appliance
Stomal appliances come in all shapes ans sizes but they all come with a foam like faceplate or disk or donut. This portion actually sticks to the skin around the stoma and the beefy stoma pokes through the middle of this piece.
A plastic bag with a lid –type edge snaps over the faceplate like the lid on a butter container. There is a clamp at the bottom of the plastic bag for emptying of the stomal contents

28. Problems…
The faceplate is supposed to stay intact for 3-5 days however… the face plate often becomes loose and leaks stool around the appliance causing much stress and frustration for the pt and the nurse
Some try and tape the loose area of the faceplate, but often times, this is not sufficient

29. When to empty the stoma
The client or nurse empties the stoma when it is 1/3 to ½ full; otherwise it will become too heavy and the faceplate will pull away from the skin

30. Types of appliances
Some appliances use stoma paste and powder to adhere the faceplate. This type becomes messy and doesn’t always stick.
Others just peel away the backing and apply the faceplate to clean, dry skin. These don’t always work either.
When skin is even slightly reddened, appliances don’t stick well
Some stoma bags contain a charcoal filter that keeps the stool’s odor in

31. Sounds of a stoma
If you are standing near a person with a stoma, you will most likely be able to hear growls, gurgles and the passing of gas into the stoma bag.
Most patients, especially teens, are quite embarrassed by this. It is important that you act professional and that you provide support to the patient. Most facilities have an E.T. nurse (enterostomal) that is available. Use her, she is a pro at stomas and really helps the patient

32. Draining a continent ileostomy
There are procedures that are done that bypass the colon for defecation. The Dr. makes a pouch in the abdominal cavity where the stool collects until the patient manually drains it. The patients takes a lubricated french rectal tube and inserts it into the belly button carefully

33. The pt has a valve just inside the belly button area that keeps the stool in until he caths it. He advances the catheter about 2 inches while bearing down or exhaling. He empties the stool into a graduate container and he can also irrigate this tube with tap water to clean it. Infection rate can be high in these patients

34. Colostomy The stool in this area is _______________
Water may be needed to irrigate the colon somewhat to loosen it up
Pts with a sigmoid colostomy may not need to wear an appliance, he may be able to irrigate his colostomy before defecation to remove the stool, sort of a bowel training technique

35. NANDA Diagnoses Constipation Risk for constipation Diarrhea
Bowel Incontinence
Toileting-Self care deficit
Depression
Situational low Self-esteem

36. THE END of Bowel Elimination

37. Chapter 20 G.I. Intubation

38. Who receives a gastrointestinal tube?
GAVAGE/GIVING or FEEDING
Pts may also receive a tube to help nourish them with liquid feedings for those who cannot eat such as anorexics, infants or children and the elderly
LAVAGE/LEAVING or DECOMPRESSION
Pts undergoing gastrointestinal or stomach surgery especially
The use of a G.I. Tube reduces or eliminates problems associated with surgery or conditions affecting the GI tract such as impaired peristalsis, vomiting, or gas accumulation

39. Intubation
Means the placement of a tube into a body structure

40. Types of NG tubes See handout please Orogastric Nasogastric
Nasointestinal
Transabdominal

41. Different types of tubes
Orogastric – insertion of a tube through the mouth into the stomach. Such as when having stomach pumped (Lavage) Ewald
Nasogastric – insertion of a tube through the nose into the stomach. Such as the basic NG tube Salem-sump (Decompression)
Nasointestinal – insertion of a tube through the nose into the intestine, this type of tube requires a guided wire and a weight on the end of the tube. An x-ray is done after the tube is in to check placement, this tube flows down into the duodenum with the help of the weighted end. In some institutions, only a Dr. can insert this tube. (Gavage) Keofeed or Dobhoff

42. Purpose of G.I. Intubation
Gavage – providing nourishment (giving)
Lavage – washing out of a cavity, irrigation (leaving)
Obtain secretions/decompression - tubing is connected to a suction machine and a collection container, removes air, gastrointestinal juices

43. Size of the intubation tube
Again, size matters…
The outside diameter of the tube (its thickness) is measured using the “French Scale”, indicated by the letter “F”
Each number on the French scale = .33mm. The larger the number on the package, the larger in diameter the tube is. 18F is bigger than a 10F tube
You must decide on how big of a tube your pt should have, the tube must fir loosely into the nares

44. Orogastric tubes - Ewald
Inserted into the mouth and down into the stomach
These are used to lavage out toxic substances that have been ingested as in a Tylenol overdose
These tubes are large in diameter to remove pill fragments and stomach debris
Because the size is so large, this tube is entered into the mouth rather than the nose

45. Nasogastric Tube – Salem-Sump
This tube is places into the nose and down into the stomach is smaller in diameter but longer in length
NG tubes can have more than 1 lumen, sort of like a Y’d tubing. One side goes to the pts nose and then to the container to drain and the other lumen (tube) hangs freely an acts as a vent so the NG will drain properly. If you plug up the vent, no drainage will occur

46. NGT’s
Can stay in for a length of time to decompress or to aid in feedings
These tubes cause the throat to become sore as in having strep throat sore. Many pts attempt to pull out their tubes while asleep because it’s a natural instinct to want that tube out
NGT’s must be taped well, in place, especially in infants and children while tube feeds are running to avoid misplacement and choking
NGT’s are easier to place when pt is asleep, not always possible though

47. Insertion of the tube (explanation of procedure)
The nurse must first explain the procedure to the patient.
Many pts refuse this placement, you can be the advocate to the pt and calm and ease their fears concerning the NG Tube
Tell the pt that the diameter of the tube is smaller than most pieces of food and all they have to do is swallow
Not always possible to do

48. Assess the nares
You are looking for nasal debris, tell pt to blow nose into Kleenex to clear the way
Assess for patency of the nares, inspect for shape, and size, deviated septum or nasal polyps
If any of these are present, notify the RN or Dr.

49. Measurement of tube Use the N.E.X. method:
Measure from the pts Nose to the Earlobe to the Xiphoid process, this is how much tubing you will insert into the pt’s nose
Mark the tubing with a permanent marker

50. Tube Placement
The nurse’s job is to minimize discomfort to the pt. This can be difficult to do if the pt is not cooperative
The nurse must also try and preserve the integrity of the nasal tissue
The nurse must place the tube into the stomach NOT the respiratory passages

51. What should the patient do
The patient should sit completely up in the bed
Tuck their chin to their chest and sip in water, swallowing it as the nurse slowly pushes the tube into the nose and back towards the pharynx and the gag reflex
The nurse can stop at any time to comfort the patient, movement of the tube should be consistent and slow, not jamming it in roughly

52. Problems that can occur during placement of the tube
During the technique of trying to pass the tube, a pt may alert you that the tube is coming out of their mouth, you should immediately stop and remove the tube.
The tube can also become coiled up in the throat while it’s on its way down, again, tube must be removed and reattempted

53. Checking placement of the tube
Once the tube is at its final mark, the nurse needs to verify that it is really in place
There are a few techniques to check tube placement…

54. 3 methods of checking tube placement
1)Aspirate fluid from the tube using a syringe
2)Aspirate fluid using a syringe and test Ph
3) Auscultate abdomen listening for air

55. 3 methods of Tube Placement
1) Aspirate fluid –
using a syringe,
pull back and see
if clear, brownish-
yellow or green
fluid can be
aspirated, the
nurse can
presume that
the tube is in
the stomach.

56. 2) Ausciltate the abdomen – the nurse instills 10ml of air or more using a syringe and listens over the “stomach area” of the abdomen with a stethoscope. If a swooshing sound is heard, the can presume that the tube is in place (most popular way of checking)

57. Tube placement
3) Testing the PH of aspirated fluids – testing the PH confirms 100% that the tube is placed correctly.
Other than obtaining a chest x-ray, THE PH TEST IS THE MOST ACCURATE TECHNIQUE FOR CHECKING NGT PLACEMENT (this is not used in all facilities)

58. Misplaced tubes 1) If the NGT is in the esophagus, the pt will belch
2) If no swoosh sound is heard, the tube may be coiled
3) If the tube is in the respiratory passage somewhere, the pt should immediately cough, this is a clear and immediate response to a foreign object entering into the resp. passages (no mistaking this)
4) If the tube comes out of the pt’s mouth, obviously, it’s not in the correct place

59. NGT used for Decompression
When bellies are full of fluid or gas after surgery when peristalsis has not returned, pts will have N/V, NGTs are to be connected to suction and THEY MUST BE WORKING CORRECTLY in order to give the pt relief

60. NGTs for decompression
Tubing is connected to suction at:
1) Low to medium suction (40-60mm hg)
2) At intermediate suction. If you put an NGT to continuous suction, it will suck and suck and suck causing GI irritation to the lining of the stomach wall. Blood will be seen in the drainage container

61. Continuous Suctioning
Can be used when the nurse is irrigating the NG with normal saline

62. Irrigating an NGT
Often times, pts will c/o nausea and may even vomit. Persons with an NGT should not vomit.
Secretions in stomach may be thick esp. after days of having tube in place.
NGT can be irrigated with NORMAL SALINE ONLY to help loosen up the thick secretions

63. Why use normal saline (NS) to irrigate
NS is isotonic = has equal
ingredients as the body does
If you use sterile water, it is hypotonic, what do the electrolytes want to do? They want to help make the solutions more equal therefore if you give sterile water, too many electrolytes will be lost

64. In the body IN GENERAL…
Normal Saline (NS) is the irrigating fluid to be used for any type of irrigation
It best meets the same needs of the body, it is most equal to the body’s fluids
We never offer ice or water to pt’s with an NGT, the fluid will get suctioned out immediately and if B.S. are not present, pt will become nauseous
NCLEX Question

65. Giving Meds to a pt with an NGT
If meds MUST be given, you must turn off the suction for up to 1 hour to allow medication to be absorbed however…
Pts without B.S. means that nothing will move on through to the intestines and pt is likely to have N/V.
If no B.S. are present, don’t bother giving meds via NGT, when you resume suction, you’ll just see the meds being suctioned out into the canister, then the pt didn’t get the meds ordered…not good

66. Securing the NGT There are several Ways to secure an NGT
Gently tape the NGT to the cheek of the same side of the nare where the tube is placed
Wrap the tubing around the upper part of the ear and allow the NGT to hang down from behind the ear. Steri-strips are used to secure the tube or plain tape
Wrap tape around the tube right at the site of entry into the nare and then apply tape to the cheek. Watch children with tubes, they pull them out

67. Deciding to remove the NGT
If the pt’s bowel sounds return and the pt is recovering well, the Dr. may order the NGT to be clamped for up to 6 hours before removal of the tube is ordered
Simply disconnect the tubing from the suction machine to allow pt to get OOB and tuck the coiled tube up and place in the pocket of the pt gown. Wait from 1-6 hours as ordered, pt usually starts to drink clear fluids and if pt has no N/V, tube can be removed. WAIT FOR THE DR.s ORDER

68. Removing the NGT
Explain to the pt that they are having their tube discontinued
Pt will usually be thrilled and may help you remove it
Remove all tape GENTLY, (tape can hurt).
Don non-sterile gloves and pinch off the tubing gently pull on tube, using both hands to walk it out of the nare. Pinching off tube will help to not make GI contents drip into nose or mouth. I usually have a chux pad ready and I lay it on the pt’s chest to catch the end of the tube. The pt may sneeze when it is out completely, the nose may run or bleed, offer tissue to the pt

69. Transabdominal tube

70. Transabdominal tubes
Otherwise known as feeding tubes for enteral nutrition
Enteral – within or by way of the intestine. Nourishment provided via the stomach or small intestine rather than by the oral route

71. Types of enteral tubes
Gastrostomy tube - A.K.A. G-tube, this tube enters the stomach. Can be used for feedings and medications
Jejunostomy tube - A.K.A J-tube, this tube enters through the jejunostomy and bi-passes the stomach and enters the small intestine
PEG tube (percutaneous endoscopic gastrostomy tube) – is a G-tube, is used for feeds and meds. Performed under endoscopy and tube is pulled out of the body
(These tubes are used when a pt needs feeding longer than 1 month and cannot eat P.O.)

72. G-Tube

74. PEG tube

75. Checking residual of these tubes is important
Once a pt is fed via one of the tubes, residual or amount of food undigested, must be assessed before feeding again
Pts can have slow digestion and their belly may still be full from the last fees, if you re-feed them, they may have vomiting d/t too full of a belly

76. Performing a tube feeding
Assess the skin around the tube site. Is it red, does it need to be cleaned.
Aspirate fluid from the tube to determine if the volume of feeds exceeds the pts physiologic capacity
Overfilling of the stomach leads to gastric reflux, regurgitation and vomiting and aspiration into lungs = pneumonia

77. Rule of thumb
The gastric residual should be no more than 100ml or no more than 20% of the previous hours tube feeding volume
When aspirating the residual, YOU MUST TAKE THE TOTAL AND RETURN THE ASPIRATED LIQUID BACK TO THE PT. This aspirate is filled with electrolytes and belongs to the pt. You would note the amount and report it to the RN or Dr. Perhaps the next feed will be held d/t the aspirated amount

78. What to do to speed up digestion and movement through the tube
Try and sit pt up
Try and place pt on their right side to increase faster emptying of the stomach
Reglan can be given
Class: GI stimulant, anti-emetic

79. TUBE FEEDING PUMP

80. Once a patient has an NGT or feeding tube…
Pt is automatically placed on I’s & O’s, you want to record all that goes in and all that comes out
Be sure to follow the order and provide the correct feeding at the correct rate
Be sure to flush the NGT or feeding tube when feed is completed with tap water

81. Bolus Feeds
Instillation of liquid nourishment x’s /day in less than 30 minutes
The usual bolus feed is ml of formula
This type and amount of feed can distend the stomach rapidly, can cause gastric discomfort, can increase the risk of reflux and aspiration

82. Be careful….
If gastric emptying is delayed or the pt is unconscious or is developmentally delayed, the pt is at greater risk for vomiting and aspiration with this method of feeding

83. Intermittent Feedings
ml is given 4-6xs/day like the bolus feeds except the intermittent feeds are given over mins, not less than 30 mins. These feed drip in by gravity
It’s a little slower of a feed to reduce the feeling of bloating

84. Changing feeding bags
You must rinse out a feeding bag between EVERY use and open a new bag every 24 hours due to the possible growth of microorganisms

85. Cyclic Feedings
Continuous feedings of liquid nourishments for 8-12 hours with a hr rest of no feeds
These pts receive these types of feeds overnight and attempt to eat orally during the day
Problems occur when the pt tries to sleep and peristalsis slows down and you try and feed your pt during the night. Bloating, nausea, vomiting and possible aspiration can occur

86. Continuous Feedings
The instillation of liquid nourishment without interruption
The rate is usually at 1.5ml/minute, a pump is needed to regulate this small amount
The formula is delivered right to the small intestine through a J tube or PEG tube
This type of feed reduces the amt of bloating, N/V, aspiration.
The pump must go wherever the pt goes, sort of inconvenient

87. Continuous Feeds
You can only put 4 hours worth of liquid feed into the bag at one time to reduce the possibility of microbes that may grow.

88. Medication
The nurse can instill medication in liquid form into the tube during a tube feed
The nurse MUST STOP THE FEED PUMP OR GRAVITY DRIPPING FEED, flush the tubing , then push each medication separately with a syringe into the feeding tube. You must flush with saline in between every med. When the meds are instilled, flush the tube again with water and resume the feed

89. Complications of tube feeds
1) ASPIRATION
Keep HOB up at all times, this becomes uncomfortable in pts who are getting continuous tube feeds, they want to lay down
Check for residual and distention before every feed if intermittent and every 2 hours in feed is continuous
Notify RN or Dr. if distention, N/V is noted. Tube feed may be with held

90. Complications of tube feeds
2.) DUMPING SYNDROME
Happens when there is a large amount of calorie-dense nutrients rapidly dumped into the small intestine
Symptoms include: dizziness, sweating, N/V – this is caused by fluid shifts from the circulating blood to the intestine and low blood sugar related to a surge of insulin, diarrhea also occurs = dehydration and dry mucosa

92. Complications of tube feeds
3) Clogging up of the tube itself, some meds clog tubes easily, you can try the following:
Using a bubbly clear soda like ginger ale or 7-up and try to use a small syringe and push and pull back on the syringe trying to push the soda into the tube. Sometimes, nurses use cranberry juice and it works!
Using meat tenderizer works, it breaks up fat in meat and it breaks up a clog in a tube, mix it with water and use the syringe method like the clear soda method

93. NANDA Diagnoses Imbalanced Nutrition: Less that body requirements
Self care deficit: Feeding
Risk for aspiration
Impaired oral mucous membranes
Diarrhea
Constipation

94. THE END