NASOGASTRIC TUBES COLOSTOMIES INSERTION; REMOVAL; CARE ASSESSING STOMAS, FITTING DEVICES

DYSPHAGIA Difficulty swallowing (dysphagia) is a symptom or complication of a number of conditions. Dysphagia leads to disability, decreased functional status, increased length of stay, risk of institutionalization, and increased mortality. Educate patients about food safety and preparation. There is higher risk for foodborne illness for older adults, the very young, and those with lowered resistance to infection.

Feeding Dependent Patients  Patients requiring assistance include those with trouble chewing or swallowing, poor vision, or difficulty holding utensils.  Assist patients in appropriate food selection.  Assess gag reflex and swallowing ability.  Encourage independence using sensory aids and adaptive devices.  Assess tray for appropriate diet.  Provide fluids; pace feeding to avoid fatigue.  Observe ability to bite, chew, and swallow.

Aspiration Precautions Aspiration often results from dysphagia. Signs and symptoms of patients at risk include: Wet voice. Weak voluntary cough. Coughing or choking on food. Prolonged swallow. Dysphagia causes decreased food intake. Diagnosis of aspiration may include: Bedside swallow assessment. 3oz-of-water swallow test. Video fluoroscopy.

Aspiration Precautions (cont’d) Diet modifications include changes in food and fluid consistency or tube feedings. Identify risk for aspiration using a screening tool. Observe patient during mealtime for dysphagia. During feeding: Do not rush patient. Provide small bites to unaffected side of mouth. Alternate solids and liquids. Inspect patient’s mouth for food pocketing. Have patient remain upright for 30 to 60 minutes. Provide oral care after meals.

 Removes gastric secretions or administers solutions into stomach ◦ Levin tube: Single lumen with holes near tip ◦ Salem sump: Has additional “pigtail” air vent lumen  Obtain assistance if patient cannot cooperate.  Place patient in high-Fowler’s position.  Select nostril with greater airflow.  Measure and mark length of tube to insert.  Lubricate end with water-soluble lubricant. Insertion, Maintenance, and Removal of a Nasogastric Tube for Gastric Decompression

Determine length of tube to be inserted.

Insertion, Maintenance, and Removal of a Nasogastric Tube for Gastric Decompression (cont’d)  Instruct patient to extend neck back.  Insert tube slowly along floor of nasal passage. ◦ Never use force. ◦ Once past nasopharynx, allow patient to relax.  Instruct patient to flex head forward. ◦ Instruct patient to swallow (sip straw if allowed). ◦ Advance tube to mark 2.5 to 5 cm (1 to 2 inches) with each swallow.  Observe for improper placement. ◦ Coughing, gagging, coiling in back of throat  Anchor tube temporarily. ◦ Verify tube placement per agency policy.

Insertion, Maintenance, and Removal of a Nasogastric Tube for Gastric Decompression (cont’d)  Secure tube using tape or fixation device.  Attach tube to suction as ordered.  Irrigate tube if ordered or needed for patency. ◦ Check for tube placement per agency policy. ◦ Remove from suction and clamp tube. ◦ Insert irrigation syringe, unclamp, and gently inject 30 mL of normal saline. ◦ Aspirate or pull back on syringe to withdraw fluid.  Document as output or intake.  Place 10 mL of air into pigtail.  Reconnect to suction or drainage.

Insertion, Maintenance, and Removal of a Nasogastric Tube for Gastric Decompression (cont’d) Discontinue nasogastric (NG) tube. Turn off suction and remove tube from it. Provide facial tissue and put towel across chest. Remove tape or fixation device. Instruct patient to hold breath. Kink tube and steadily and smoothly pull it out into towel. Clean naris and provide mouth care.

perform-nasogastric-tube-insertion / perform-nasogastric-tube-insertion

Insertion and Removal of a Small-Bore Feeding Tube Placement of a feeding tube requires a health care provider’s order. Tube placement must be confirmed before feeding or medication administration. Determine appropriate naris for insertion. Position patient in high-Fowler’s position. Determine and mark tube length to be inserted.

Insertion and Removal of a Small-Bore Feeding Tube (cont’d) Instruct patient to extend neck back. Insert lubricated tube slowly along floor of nasal passage. Never use force. Once past nasopharynx allow patient to relax. Instruct patient to flex head forward. Instruct patient to swallow (sip straw if allowed). Advance tube to mark 1 to 2 inches with each swallow.

Insertion and Removal of a Small-Bore Feeding Tube (cont’d) Observe for improper placement. Coughing, gagging, coiling in back of throat Withdraw tip of tube to oropharynx and attempt to reinsert. Anchor tube temporarily. Verify tube placement per agency policy. Anchor tube when proper placement is confirmed.

Verifying Feeding Tube Placement and Irrigation  Tube placement must be confirmed before use.  Following initial x-ray film confirmation; verify tube position every 4 to 6 hours and as needed. ◦ Observe characteristics of fluid aspirated from tube. ◦ Test the pH of aspirated fluid.  Tube irrigation maintains tube patency: ◦ Before, between, and after medications and feedings. ◦ 30 mL of plain water is the preferred irrigation solution.  Sterile water is used for immunocompromised or critically ill patients.  Allow gravity infusion of irrigating solution.

Administering Nasogastric, Gastrostomy, and Jejunostomy Tube Feedings  Surgically placed tubes provide nutrition. ◦ Systems are open (containers must be filled) or ready- to-hang closed.  Administer feeding by gravity or pump. ◦ Assess bowel sounds and abdominal status. ◦ Verify tube placement. ◦ Elevate head of bed at least 30 degrees, preferably 45. ◦ Check gastric residual volume. ◦ Administer continuous infusion or intermittent bolus. ◦ Flush tube with 30 mL of water or appropriate solution.

Site Care of Enteral Feeding Tubes Nasogastric and gastric tube exit sites require routine assessment and care. Inspect skin for inflammation, bleeding, excoriation, drainage, and tenderness. Cleanse site with warm water and mild soap. Replace fixation device or tape. Place gauze dressing (over external bar of gastric tube) if ordered.

Divisions of the Large Intestine

STOMA CARE  A stoma is an opening in the abdominal wall for fecal or urinary elimination.  The surgeon or ostomy care nurse determines the optimal location for the stoma.  Do not act offended by odor or appearance.  Assist the patient to be independent in care.  Provide culturally sensitive care.  Assign gender-congruent caregivers if possible.

STOMA CARE  Proper stoma placement reduces the risk of poor stomal healing or skin irritation because of drainage.  Assess new stomas for edema and proper fit of pouching appliance.  Perform proper hand hygiene.  Assist patient with hand hygiene during self- care.  Position patient so stoma care can be observed and self-care can be taught.

Pouching a Bowel Diversion  Pouches protect the skin from effluent and provide a barrier against odor.  Revise the pouch to meet the changing stoma size and body contours. ◦ One-piece and two-piece systems are available. ◦ Cleanse peristomal area gently with soap and water. ◦ Measure stoma. ◦ Trace pattern. ◦ Cut opening in pouch. ◦ Apply pouch and close end.

Cutting opening of pouch to fit stoma (Courtesy ConvaTec, Princeton, N.J.)