1. Chapter 44 Nutrition /Naso-Gastric Tubes
ATI Skill Checklist N/G Tube Insertion
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.

2. 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); parenteral nutrition (PN)
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.

3. Case Study
Mrs. Gonzalez is a 65-year-old Hispanic woman who comes to the emergency department with slurred speech, right facial droop, and weakness in her upper and lower right-side extremities. She is admitted to the hospital with a diagnosis of acute stroke.
She has a daughter and two teenage grandchildren who live in another town nearby.
[Ask the class: What special nutritional needs will Mrs. Gonzalez face during her recovery? Discuss.]

4. Energy Requirements
Basal metabolic rate—the energy needed to maintain life-sustaining activities for a specific period of time at rest
Resting energy expenditure (REE) (aka resting metabolic rate)—the amount of energy that an individual needs to consume over a 24-hour period for the body to maintain all of its internal working activities while at rest
In general, when energy requirements are completely met by kilocalorie intake in food, weight does not change.
The body requires fuel to provide energy for cellular metabolism and repair, organ function, growth, and body movement. Life-sustaining activities include breathing, circulation, heart rate, and temperature.
Factors such as age, body mass, gender, fever, starvation, menstruation, illness, injury, infection, activity level, and thyroid function affect energy requirements.
Factors that affect metabolism include illness, pregnancy, lactation, and activity level.
When the kilocalories ingested exceed a person’s energy demands, the individual gains weight. If the kilocalories ingested fail to meet a person’s energy requirements, the individual loses weight.

5. Scientific Knowledge Base: Nutrients
Water
All cell function depends on a fluid environment.
Vitamins
Essential for metabolism
Water-soluble or fat-soluble
Minerals
Catalysts for enzymatic reactions
Macrominerals; trace elements
Humans are water-based systems! In all, 60% to 70% of total body weight is water. Water is critical because cell function depends on a fluid environment.
Vitamins are organic substances present in small amounts in foods that are essential to normal metabolism. Fat-soluble vitamins: A, D, E, K. Water-soluble vitamins: C and B complex.
Minerals are inorganic elements essential to the body as catalysts in biochemical reactions. We need 100 mg or more daily of macrominerals and 100 mg or less of trace elements.

6. Digestion Digestion Absorption Metabolism and storage of nutrients
Begins in the mouth and ends in the small and large intestines
Absorption
Intestine is the primary area of absorption.
Metabolism and storage of nutrients
Consist of anabolic and catabolic reactions
Elimination
Chyme is moved through peristalsis and is changed into feces.
Digestion causes food to break down to simplest form for absorption, mainly in the small intestines. Ingestion is the taking in of food.
Enzymes are the catalysts that speed up chemical reactions. Food moves through the GI tract through peristalsis, or wavelike muscular contractions. The food mass in liquefied form is called chyme.
Absorption uses the processes of active transport, passive diffusion, osmosis, and pinocytosis.
[See Box 44-1 on text page 1000 and Table 44-1 Mechanisms for Intestinal Absorption of Nutrients.]
Metabolism refers to all of the biochemical reactions within the cells of the body. Anabolism is the building of more complex biochemical substances through synthesis of nutrients. Catabolism is the breakdown of biochemical substances into simpler substances; it occurs during physiological states of negative nitrogen balance.
Metabolic reactions include glycogenolysis, glycogenesis, and gluconeogenesis.
As feces move toward the rectum, water is absorbed in the mucosa. The longer the material stays in the large intestines, the firmer are the feces. Feces contains cellulose, indigestible substances, GI tract cells, digestive secretions, water, and microbes.
[See also Figure 44-1 on text p. 999 Summary of digestive system anatomy/organ function.]

7. Dietary Guidelines Dietary reference intakes (DRIs)
Acceptable range of quantities of vitamins and minerals for each gender and age group
Food guidelines
Dietary Guidelines, average daily consumption
Daily values
Needed protein, vitamins, fats, cholesterol, carbohydrates, fiber, sodium, and potassium
The U.S. Department of Agriculture and the U.S. Department of Health and Human Services publish the Dietary Guidelines (see Box 44-2 on text page 1001).
Students need to be cognizant of the needs of the young, the old, and the culturally diverse to ensure that these populations receive the nutrients necessary to meet their needs.
Four components of dietary reference intakes (DRIs):
1. Estimated average requirement (EAR)—amount of nutrient that appears sufficient to maintain a specific body function for 50% of population based on age and gender 2.
2. Recommended dietary allowance (RDA)—average needs of 98% of population, not exact needs of an individual
3. Adequate intake (AI)—suggested intake for individuals based on observed or experimentally determined estimates of nutrient intakes used when not enough evidence to set RDA
4. Tolerable upper intake level (UL)—highest level that poses no risk of adverse health events.
The Food and Drug Administration (FDA) created daily values for food labels in response to the 1990 Nutrition Labeling and Education Act. Daily values did not replace RDAs but provided a separate, more understandable format for the public. Daily values are based on percentages of a diet consisting of 2000 kcal/day for adults and children 4 years or older.

8. Case Study (cont’d)
Mrs. Gonzales is awake and alert in her hospital room, yet is drooling from the right side of her mouth. When she tries to drink water, she starts to cough. The physician has ordered nothing by mouth (NPO).
Evaluation by the speech language pathologist (SLP) indicates inadequate clearance of food and liquid from the vocal folds and aspiration of thickened liquids.
Mrs. Gonzalez has trouble swallowing with oropharyngeal dysphagia. The SLP recommends enteral feedings, and speech and swallowing therapy to help her return to oral feedings.
[Ask the class: Were you able to predict that Mrs. Gonzales would receive enteral feedings? What challenges do her nurses face in helping her progress back to oral feedings?]

9. Case Study (cont’d)
Matt is a nursing student assigned to Mrs. Gonzalez. As he prepares to assess her, he recalls information about the effects of dysphagia on nutrition and rehabilitation. He will assess Mrs. Gonzales’ weight, weight history, diet history, and cultural customs.
Matt knows to consult with a registered dietitian (RD) to assess Mrs. Gonzales’s nutritional status and interventions. Matt is responsible for inserting Mrs. Gonzalez’s small-bore nasogastric feeding tube and starting her tube feedings.
The RD has recommended continuous tube feeding for 12 hours during the day.

10. 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 Critical thinking model for nutrition assessment; and Figure 44-4 on text p Mini-Nutritional Assessment (MNA).]

11. Assessment (cont’d)
Anthropometry is a measurement system of the size and makeup of the body.
An ideal body weight (IBW) provides an estimate of what a person should weigh.
Body mass index (BMI) measures weight corrected for height and serves as an alternative to traditional height-weight relationships.
Laboratory and biochemical tests
Serial measures of weight over time provide more useful information than a single measurement. The patient needs to be weighed at the same time each day, on the same scale, and with the same clothing or linen.
Rapid weight gain or loss is important to note because it usually reflects fluid shifts. One pint or 500 mL of fluid equals 1 lb (0.45 kg).
No single laboratory or biochemical test is diagnostic for malnutrition. Factors that frequently alter test results include fluid balance, liver function, kidney function, and the presence of disease.
Common laboratory tests used to study nutritional status include measures of plasma proteins such as albumin, transferrin, prealbumin, retinol binding protein, total iron-binding capacity, and hemoglobin.
Nitrogen balance can be calculated to determine serum protein status.
Factors that affect serum albumin levels include hydration; hemorrhage; renal or hepatic disease; large amounts of drainage from wounds, drains, burns, or the GI tract; steroid administration; and exogenous albumin.

12. 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 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 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 Critical thinking model for nutrition assessment; and Box 44-7 on text p Causes of Dysphagia.]

13. Case Study (cont’d) Assessment findings:
Mrs. Gonzales starts to cough when she tries to drink water.
Mrs. Gonzales is unable to swallow and aspirates pills and thickened liquid.
Lung sounds are clear. Respirations are regular at 12/min. She has no dyspnea. Oxygen saturation is 96% on room air.
Enteral nutrition will begin at 60 mL/hr.
[Matt assessed Mrs. Gonzalez for risk of aspiration, evaluated Mrs. Gonzalez’ swallowing ability, monitored her respiratory status, and assessed her nutritional status.
What diagnosis would you expect?]

14. 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 Nursing Diagnostic Process: Imbalanced Nutrition: Less than Body Requirements; and Figure 44-5 Concept map on text p ]

15. Case Study (cont’d)
Diagnosis: Risk for aspiration related to impaired swallowing
Goals:
Mrs. Gonzales will receive adequate nutrients through enteral tube feeding without aspiration by the time of discharge.
Mrs. Gonzalez will regain swallowing ability from speech therapy by the time of discharge.
[Ask the class: What are some expected outcomes for these goals? Discuss:
Mrs. Gonzalez’s weight at discharge will be within 2 lbs of admission weight.
Mrs. Gonzalez will not exhibit signs of aspiration before discharge.
Mrs. Gonzalez’ albumin and prealbumin levels will remain normal before discharge.
Mrs. Gonzalez will progress to an oral diet before discharge to a restorative care facility.]

16. 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 and parenteral 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 Nursing Diagnostic Process: Imbalanced Nutrition: Less than Body Requirements; Figure 44-5 Concept map on text p. 1012; Nursing Care Plan on text pp Imbalanced Nutrition: Less Than Body Requirements; and Figure 44-6 on text p Critical thinking model for nutrition planning.]

17. Other Causes of Dysphagia
Obstructive lesions in the throat or esophagus, such as tumors
Central nervous system infections
Head injury
Cerebral palsy
Parkinson's disease
Huntington's disease

18. Some causes of dysphagia include:
Myasthenia gravis
Amyotrophic lateral sclerosis (ALS)
Multiple sclerosis
Scleroderma
Infection with herpes simplex virus or yeast
Narrowing of the esophagus after infection or irritation
Injury to the swallowing muscles from chemotherapy and radiation for cancer

19. Enteral Tube Feeding
Enteral nutrition (EN) 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 on text p 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 on text p Advancing the Rate of Tube Feeding.]

21. 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.
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 Enteral Tube Feeding Complications.]
[Shown is text Figure 44-8 from p ]

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

25. Chest Xray Representing a Properly placed NG tube

26. Chest xray NG tube in left main stem Bronchi

28. pH Measurement for Tube Location
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 on text p Procedural Guidelines: Obtaining Gastrointestinal Aspirate for pH Measurement, Large-Bore, and Small-Bore Feeding Tubes: Intermittent and Continuous Feeding; and Box on text p Evidence-Based Practice: Accuracy in Determining Placement of Feeding Tubes.]
[Figures are from Box ]
See Box on text p. 1020

30. Benzocaine Spray
Viscous Lidocaine

31. 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.

32. 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.

34. Case Study (cont’d) Nutritional management Aspiration precautions
Insert feeding tube as ordered.
Initiate enteral feeding as prescribed.
Advance tube feeding as tolerated; monitor for tolerance.
Aspiration precautions
Position Mrs. Gonzalez with head of bed elevated a minimum of 30 degrees.
Check tube placement every 4 to 6 hours.
Check gastric residual volume every 4 hours.
Continue with speech therapy.
[Discuss the rationales for these interventions:
The enteral tube feeding will allow for safe provision of nutrients while swallowing is rehabilitated with the assistance of the speech-language pathologist (SLP).
Tube feeding is initiated at a low rate of infusion and is increased slowly to allow for maximum tolerance.
Abdominal pain, large volume of gastric residuals, and diarrhea are signs of feeding intolerance and need to be evaluated promptly.
Head of bed elevated a minimum of 30 to 40 degrees decreases the risk for aspiration.
Improperly positioned tubes increase the risk for aspiration.
Gastric residual volume indicates whether gastric emptying is delayed. Delayed gastric emptying increases the risk for aspiration.
Regularly provided speech therapy will assist the patient in regaining the ability to swallow foods and liquids.
Speech therapy includes trials of various consistencies of foods and liquids. Aspiration of food and liquids lead to chest congestion and pneumonia.]

35. 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

36. 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

37. 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 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 ]

38. Restorative and Continuing Care
Medical nutrition therapy (MNT)
Specific nutritional therapy usage for treating illness, injury, or a certain condition
Necessary for
Metabolizing certain nutrients
Correcting nutritional deficiencies
Eliminating foods that worsen disease states
Most effective with collaborative health care team and dietitian
Optimal nutrition is significant in health and illness and thus is modified in patients with particular diseases; thus medical nutrition therapy (MNT) is needed. The next few slides discuss the various important disease states dependent on MNT; these include both acute and chronic disease states.

39. Case Study (cont’d)
What nursing actions are appropriate for evaluating whether goals have been met?
Consider the patient’s perspective.
Check measurable outcomes.
Consult with interdisciplinary staff.
[Nursing actions taken to verify achievement of outcome include:
Asking Mrs. Gonzalez if she is experiencing any gastrointestinal discomfort
Weighing Mrs. Gonzalez weekly
Monitoring her laboratory values
Asking the SLP about Mrs. Gonzalez’ swallowing rehabilitation]

40. 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 Critical thinking model for nutrition evaluation.]

41. Case Study (cont’d)
Matt sees Mrs. Gonzalez before discharge to a restorative care facility for rehabilitation before returning home. Mrs. Gonzalez now is able to consume all of her required nutrients with a ground diet and nectar-thickened liquids. Matt removes the feeding tube in preparation for her transport to the new facility.
Matt advises Mrs. Gonzalez to continue the care plan and emphasizes that it is important to continue speech therapy.
Matt also discusses the importance of compliance with diet modifications until swallowing function returns completely.
[Ask the class: What would Matt write in a documentation note? Discuss.]

43. 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,
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.

44. The Miller-Abbott Tube (Active Gastric Hemorrhage)

47. 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.

48. 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.

51. 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.

53. 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)

54. 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].

55. 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.

56. Mechanisms of postoperative gastrointestinal discomfort

57. 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.

58. 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.
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.

59. BIG RED

60. 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.