Chapter 44 Nutrition /Naso-Gastric Tubes Revised ATI Skill Checklist N/G Tube Insertion & Discontinuation-CANVAS Gastrostomy Tube Feeding/Med Administration Managing Suction N/G Tube Decompression Nutrition is a basic component of health and is essential for normal growth and development, tissue repair and maintenance, cellular metabolism, and organ function. Ingestion of a diet balanced with carbohydrates, fats, proteins, vitamins, and minerals provides the essential nutrients to carry out the normal physiological functioning of the body throughout the life span.

Objectives: Nasogastric Tubes NG Tubes NG Tubes 1. Describe the procedure for initiating; maintaining; and removing nasogastric tubes. 2. Discuss the client’s teaching in relation to client’s expectation and in preparation for their participation in the procedure. 3.Explain the nurse’s role and responsibilities in the management of nasogastric tubes with and without suction. 4. Discuss the nurse’s role and responsibilities in the management of enteral feedings.

Background Food security is critical for all members of a household. Food holds symbolic meaning. Medical nutrition therapy uses nutrition therapy and counseling to manage disease. Type 1 diabetes mellitus Hypertension Inflammatory bowel disease Enteral nutrition (EN); total parenteral nutrition (TPN) Food security means that all household members have access to sufficient, safe, and nutritious food to maintain a healthy lifestyle; sufficient food is available on a consistent basis; and the household has resources to obtain appropriate food for a nutritious diet. Giving or taking food is part of ceremonies, social gatherings, holiday traditions, religious events, the celebration of birth, and the mourning of death. The difficulty of the decision to withdraw food in a terminal illness, even in the form of intravenous (IV) nutrients, is a testament to the symbolic power of food and feeding. In some illnesses such as type 1 diabetes mellitus (DM) or mild hypertension, diet therapy is often the major treatment for disease control. Other conditions such as severe inflammatory bowel disease require specialized nutritional support such as enteral nutrition (EN) or parenteral nutrition (PN). Current standards of care promote optimal nutrition in all patients.

Assessment Screening a patient is a quick method of identifying malnutrition or risk of malnutrition using sample tools: Height Weight Weight change Primary diagnosis Comorbidities Screening tools A nutritional assessment is more than taking a diet history. Some prescription drugs, many over-the-counter drugs, and herbal/natural therapy can affect a patient’s nutritional state. It is also important to know food interactions and medication administration, especially between milk and citrus fruits and between juices and alcohol. Screening is an essential part of initial assessment. Standardized nutrition screening tools include Subjective Global Assessment (SGA) (an inexpensive technique to predict nutrition-related complications), Mini-Nutritional Assessment (MNA) (an 18-item tool divided into screening and assessment; used to assess older adults in home care programs, nursing homes, and hospitals), and the Malnutrition Screening Tool (MST) (an effective measure of nutritional problems in a variety of health care settings). Identification of risk factors such as unintentional weight loss, the presence of a modified diet, or the presence of altered nutritional symptoms (i.e., nausea, vomiting, diarrhea, and constipation) requires nutritional consultation. [See also Figure 44-3 on text p. 1007 Critical thinking model for nutrition assessment; and Figure 44-4 on text p. 1008 Mini-Nutritional Assessment (MNA).]

Assessment (cont’d) Dietary and health history Health status; age; cultural background; religious food patterns; socioeconomic status; personal food preferences; psychological factors; use of alcohol or illegal drugs; use of vitamin, mineral, or herbal supplements; prescription or over- the-counter (OTC) drugs; and the patient’s general nutrition knowledge Physical examination Dysphagia (difficulty swallowing) The diet history focuses on a patient’s habitual intake of foods and liquids and includes information about preferences, allergies, and other relevant topics such as the patient’s ability to obtain food. Gather information about the patient’s illness/activity level to determine energy needs and compare food intake. [Review Box 44-6 on text p. 1009 Nursing Assessment Questions.] Physical examination is one of the most important aspects of nutritional assessment because improper nutrition affects all body systems. [Review Table 44-4 on text p. 1011 Physical Signs of Nutritional Status.] During the physical examination, you will assess for dysphagia. This may cause difficulty for patients while eating, drinking, or taking medications. Validated screening tools for dysphagia include Bedside Swallowing Assessment, Burke Dysphagia Screening Test, Acute Stroke Dysphagia Screen, and Standardized Swallowing Assessment. Dysphagia leads to disability or decreased functional status, increased length of stay and cost of care, increased likelihood of discharge to institutionalized care, and increased mortality. [See also Figure 44-3 on text p. 1007 Critical thinking model for nutrition assessment; and Box 44-7 on text p. 1010 Causes of Dysphagia.]

Nursing Diagnosis Risk for aspiration Diarrhea Deficient knowledge Readiness for enhanced nutrition Feeding self-care deficit Impaired swallowing Imbalanced nutrition: more than body requirements Imbalanced nutrition: less than body requirements Risk for imbalanced nutrition: more than body requirements Possible nursing diagnoses are shown on the slide. Nursing diagnoses may be related to actual nutrition problems (e.g., inadequate intake) or to problems that place the patient at risk for nutritional deficiencies such as oral trauma, severe burns, and infections. [See also Box 44-8 on text p. 1010 Nursing Diagnostic Process: Imbalanced Nutrition: Less than Body Requirements; and Figure 44-5 Concept map on text p. 1012.]

Planning Nutrition education and counseling are important for all patients to prevent disease and promote health. Refer to professional standards for nutrition. Collaboration with a registered dietitian (RD) helps develop appropriate nutrition treatment plans. Considerations: Perioperative food intake Enteral (Tubes) and Parenteral (Central lines-IV) feedings Assistive devices Planning to maintain optimal nutritional status requires a higher level of care than just nutritional problem corrections. Referring to professional standards for nutrition is especially important during this step because published standards are based on scientific findings. Goals and outcomes of care reflect a patient’s physiological, therapeutic, and individualized needs. Patients on therapeutic diets need to understand the implications of their diets and how prescribed diets help to control their illnesses. Individualized planning is essential. Explore patients’ feelings about their weight and diet, and help them set realistic and achievable goals. During acute illness or surgery, intake of food is often altered in the perioperative period. The priority of care is to provide optimal preoperative nutrition support in patients with malnutrition. The priority for the resumption of food intake after surgery depends on the return of bowel function, the extent of the surgical procedure, and the presence of any complications. It is important that discharge planning include nutritional interventions as patients return to their homes or extended care facilities. Enteral tube feedings are often administered into the stomach or intestines via a tube inserted through the nose or a percutaneous access. These enteral feedings supplement a patient’s oral nutritional intake in the home, acute care, extended care, or rehabilitation setting when they cannot meet their nutritional needs by mouth. Patients who cannot tolerate nutrition through the GI tract receive parenteral nutrition, a solution consisting of glucose, amino acids, lipids, minerals, electrolytes, trace elements, and vitamins, through an indwelling peripheral or central venous catheter. When patients have difficulty feeding themselves, occupational therapists work with them and their families to identify assistive devices. [See also Box 44-8 on text p. 1010 Nursing Diagnostic Process: Imbalanced Nutrition: Less than Body Requirements; Figure 44-5 Concept map on text p. 1012; Nursing Care Plan on text pp. 1013-1014 Imbalanced Nutrition: Less Than Body Requirements; and Figure 44-6 on text p. 1015 Critical thinking model for nutrition planning.]

Enteral Tube Feeding Enteral nutrition (EN-Tubes) provides nutrients into the GI tract. It is physiological, safe, and economical nutritional support. Nasogastric, jejunal, or gastric tubes Surgical or endoscopic placement Nasointestinal Gastrostomy Jejunostomy PEG (percutaneous endoscopic gastrostomy) PEJ (percutaneous endoscopic jejunostomy) Risk of aspiration When oral feeding assistance is inadequate in providing appropriate nutrition, enteral or parental feeding is required. EN is the preferred method of meeting nutritional needs if a patient is unable to swallow or take in nutrients orally, yet has a functioning GI tract. [Box 44-11 on text p. 1019 lists indications for EN or PN.] Patients at low risk for gastric reflux receive gastric feedings; however, if risk of gastric reflux, which leads to aspiration, is present, jejunal feeding is preferred. Types of formulas include Polymeric: milk-based, blenderized; the patient’s gastrointestinal tract needs to be able to absorb whole nutrients Modular: single-macronutrient (protein, glucose, polymers, or lipids) formulas are added to other foods to meet patients’ needs Elemental formulas: predigested nutrients, easier for partially dysfunctional gastrointestinal tract to absorb Specialty formulas: designed to meet specific nutritional needs in certain illnesses Before beginning a tube feeding, you will learn in the skills lab to flush the line with a small amount of water to ensure that the tube is clear and patent. Tube feedings typically are started at full strength at slow rates. Increase the hourly rate every 8 to 12 hours per health care provider’s order if no signs of intolerance appear. Feeding by the enteral route reduces sepsis, minimizes the hypermetabolic response to trauma, decreases hospital mortality, and maintains intestinal structure and function. Tubes are inserted through the nose (nasogastric or nasointestinal), surgically (gastrostomy or jejunostomy), or endoscopically (percutaneous endoscopic gastrostomy or jejunostomy). If for less than 4 weeks total, nasogastric or nasojejunal feeding tubes may be used. Surgical or endoscopically placed tubes are preferred for long-term feeding. A serious complication associated with enteral feedings is aspiration of formula into the tracheobronchial tree, which leads to infection. [Review Box 44-12 on text p. 1019 Advancing the Rate of Tube Feeding.]

Enteral Tubes Most health care settings use small-bore feeding tubes because they create less discomfort for a patient. For the adult, most of these tubes are 8- to 12-French and 36 to 44 inches long. A stylet is often used during insertion of a small-bore tube to stiffen it. The stylet is removed when correct positioning of the feeding tube is confirmed by x-ray esp. Dobbhoff. Shown are small-bore enteral tubes. Most health care settings use small-bore feeding tubes because they create less discomfort for a patient. For the adult, most of these tubes are 8- to 12-French and 36 to 44 inches (90 to 110 cm) long. A stylet is often used during insertion of a small-bore tube to stiffen it. The stylet is removed when correct positioning of the feeding tube is confirmed. Skill 44-3 describes the procedure for initiating nasogastric, gastrostomy, and jejunostomy enteral feedings. Measurement of the pH of secretions withdrawn from the feeding tube helps to differentiate the location of the tube. [Review Table 44-7 on text p. 1022 Enteral Tube Feeding Complications.] [Shown is text Figure 44-8 from p. 1020.]

Ear lobe to xiphoid process NG TUBE INSERTION Ear lobe to xiphoid process Ear lobe to Nose Tip Ear lobe to nose tip

Chest Xray Representing a Properly placed NG tube

Chest xray NG tube in left main stem Bronchi

pH Measurement for Tube Location Continous pH=5 Instestine pH=6 pH=1to 4 S T O M A C H Stomach Measurement of pH of secretions withdrawn from the feeding tube helps to differentiate the location of the tube. At present, the most reliable method for verification of placement of small-bore feeding tubes is x-ray film examination. On the left are gastrointestinal contents. A, Stomach. B, Stomach. C, Intestinal tract. The photo on the right shows a comparison of the pH strip with a color chart. [See Box 44-13 on text p. 1020 Procedural Guidelines: Obtaining Gastrointestinal Aspirate for pH Measurement, Large-Bore, and Small-Bore Feeding Tubes: Intermittent and Continuous Feeding; and Box 44-14 on text p. 1021 Evidence-Based Practice: Accuracy in Determining Placement of Feeding Tubes.] [Figures are from Box 44-13.] See Box 44-13 on text p. 1020

Securing Device

Water-Soluble Lubricant Benzocaine Spray Penlight Penlight Penlight Viscous Lidocaine Tissues Straw Glass Tongue Blade

TYPES OF NASOGASTRIC TUBES The first nasogastric tubes were made of soft rubber. Recently, tubes have been made of silastic and polyethylene compounds. These tubes can be inserted more easily and also cause fewer medical problems for the patient. There are fewer instances of inflamed tissues. With the exception of this change, nasogastric tubes are very much the same today as they have been for the last three decades. The most commonly used nasogastric tube is the Levin tube. Other nasogastric tubes include the Salem-sump tube, the Miller-Abbott tube, and the Cantor tube.

The Levin Tube The actual tubing is referred to as lumen. The Levin tube is a one-lumen nasogastric tube. The Salem-sump nasogastric tube is a two-lumen piece of equipment; that is, it has two tubes. The Levin tube is usually made of plastic with several drainage holes near the gastric end of the tube. There are graduated patient depth markings. This nasogastric tube is useful in instilling material into the stomach or suctioning material out of the stomach.

Levin Tube-Usually for feedings

ENTERAL TUBE FEEDING COMPLICATIONS TABLE 44-7 (Pg.1022) Pulmonary Aspiration Diarrhea Constipation Tube Occlusion Tube Displacement Abdominal Cramping-Nausea/Vomiting Delayed Gastric Emptying Serum Electrolyte Imbalance Fluid Overload Hyperosmolar Dehydration

Quick Quiz! 2. You receive an order to begin enteral tube feedings. The first step is to A. Place the patient in a prone position. B. Irrigate the tube w/normal saline. C. Check to see that the tube is properly placed. D. Introduce a small amount of fluid into the tube before feeding. Answer: D

Parenteral Nutrition Nutrients are provided intravenously. Patients unable to digest or absorb enteral nutrition or are in highly stressed physiological states: Sepsis Head injury Burns Peripheral(PIC line) or central line Initiating parenteral nutrition Preventing complications Parenteral nutrition consists of concentrated nutrients delivered directly to the superior vena cava near the right atrium of the heart. Intravenous fat emulsions sometimes are added to parenteral nutrition (PN) to provide supplemental kilocalories, prevent essential fatty acid deficiencies, and help control hyperglycemia during periods of stress. PN greater than 10% dextrose requires a central venous catheter, placed into a high-flow central vein. Patients with short-term nutritional needs often receive IV solutions less than 10% in the peripheral vein. Placement of the line needs to be confirmed by x-ray. Before beginning any PN infusion, verify the health care provider’s order and inspect the solution for particulate matter or a break in the fat emulsion. Complications can occur at the site, with tubing, with infusion rate, and with electrolyte imbalances. Examples of complications include pneumothorax, air embolus, catheter occlusion, catheter sepsis, osmotic diuresis, and dehydration. The goal is to move patients from PN to enteral nutrition (EN) and/or oral feeding. When 1/3 to 1/2 of kilocalorie needs are met, PN is decreased to half the original volume. When 75% of needs are met by EN or dietary intake, PN therapy is discontinued, preparing the patient for discharge and restorative and continual care. [Review Table 44-8 Metabolic Complications of Parenteral Nutrition on text p. 1023.]

Evaluation Multidisciplinary collaboration remains essential in providing nutritional support. Changes in condition indicate a need to change the nutritional plan of care. Consider the limits of patients’ conditions and treatments, their dietary preferences, and their cultural beliefs when evaluating outcomes. Upon care plan completion, it is necessary to evaluate prior interventions and responses for optimal outcomes. If ongoing nutrition therapies do not result in successful outcomes, patients expect nurses to recognize this and alter the plan of care accordingly. When outcomes are not met, ask questions such as “How has your appetite been?” “Have you noticed a change in your weight?” “How much would you like to weigh?” or “Have you changed your exercise pattern?” [Figure 44-9 from text p. 1025 Critical thinking model for nutrition evaluation.]

Anyone ready for repairs?

NG Tubes for Decompression Refer to ATI (Accepted Practice) N/G intubation is used for several purposes: to decompress the stomach and remove gas and fluid; (gravity or suction) to lavage the stomach to remove ingested toxins; to diagnose problems with GI motility; to treat an obstruction; to compress a bleeding site; to aspirate contents for a gastric analysis; and to administer contrast for a radiographic study.

The Miller-Abbott Tube (Active Gastric Hemorrhage)

NG Tubes for Decompression Gastric decompression is indicated for obstruction or paralytic ileus and when surgery is performed on the stomach or intestine. The tube usually remains in place until normal bowel function returns as evidenced by normal bowel sounds on auscultation and/ or when the pt. begins to pass flatus.

The Salem-Sump Tube This nasogastric tube is a two-lumen piece of equipment. It has a drainage lumen and a smaller secondary tube that is open to the atmosphere. The major advantage of this two-lumen tube is that it can be used for continuous suction. The continuous airflow reduces the frequency of stomach contents being drawn up into the whole of the lumen which is in the patient's stomach.

The Salem-Sump Tube Salem-SumpTube-Usually for Decompression, Medications, Feedings

Anti-reflux valve

NG Tubes for Decompression With gastric decompression, stomach contents are removed to relieve the stomach and intestines of the pressure caused by the accumulation gastrointestinal air and fluid. The N/G tube is connected to suction to facilitate decompression by removing the contents.

Suction Canister-DocumentDrainage

Postoperative Gastrointestinal Discomfort Postoperative gastrointestinal discomfort is not new. The earliest written records described an unchanging physiological response following any type of surgery, with greater severity after laparotomy. Clinically, there are three typical consequences of surgery, namely dilatation of the stomach, ileus and PONV. (Post-Op Nausea & Vomiting)

Postoperative Gastrointestinal Discomfort Dilatation of the stomach is related to the common postoperative increase in swallowing [1]. Air carried into the stomach with each swallow induces gastric discomfort, and when present in great quantities the air passes into the intestine, resulting in abdominal distension. The greatest incidences were found in patients who had undergone surgery to the biliary tract or uterus. In the majority of the cases, distension was apparent after 24 hours and the usual duration was 48 to 72 hours [2].

Postoperative Gastrointestinal Discomfort Decompression relieves gastric discomfort, but the irritating presence of the tube promotes swallowing. In any case, these physiological events must be distinguished from acute gastric dilatation and acute colonic pseudo-obstruction, which are responsible for major abdominal distension in very specific circumstances.

Mechanisms of postoperative gastrointestinal discomfort

NG Tubes for Decompression For some patients the tube is placed during surgery and used post-op for gastric decompression. This is usually used for patients who undergo extensive surgery or who are at a high risk for prolonged postoperative ileus. Follow the surgeon’s post op order for specific instruction on suction, irrigation etc.

GASTRIC LAVAGE Gastric Lavage is the irrigation of the stomach. This is usually performed is acute care settings where poisonings or drug overdoses for which swift removal of stomach contents is required. (ER) In this situation an orogastric or nasogastric tube is inserted both to aspirate gastric contents and to instill a rinsing solution into the stomach to dilute the toxic substance.

GASTRIC LAVAGE Patients who have gastric bleeding are sometimes treated with iced saline lavage, which involves instillation and aspiration of iced saline through an N/G tube to empty the stomach of blood and to slow the bleeding (vasoconstriction) at its source. (Controversial due to the Vasovagal response which increases acid reflux) Norepinephrine is sometimes used as a vasoconstrictor at the site but the hypertensive response must be closely monitored. Lavage may also be used as therapy for hypo or hyperthermia to help stabilize body temperature.

Questions??? Thank You.