1. Nasogastic tube

2. Out line Define the nasogastric tube
Discuss the types of nasogastric tube .
List the purpose of using the nasogastric tube
Discuss insertion nasogastric tube
Discuss removing nasogastric tube
Discuss administering a tube feeding
Discuss Irrigating Nasogastric Tube
Explain the procedure.
List the potential complications of Nasogastric Tube.
Demonstrate the procedure.

3. Introduction
Gastrointestinal intubation is inserting of rubber or plastic tube into the stomach , duodenum or intestinal
The tube inserted through mouth .nose , or abdominal ( gastrostomy .jejunostomy )
The tube short , medium , long

4. Types of Tubes Short- Nasogastric tube
Introduced from the nose to the stomach
Levin and Gastric (Salem) Sump
Used to remove gas and fluid from the upper GI tract or to obtain a specimen of gastric contents
Sometimes used for medications or feedings ( gavage )

5. Levin Tube Single Lumen (hollow part of tube) Size 14-18 French
Made of plastic or rubber with opening near tip
It is 125 cm long
Circular markings on the tube serve as insertion guides

6. Gastric (Salem) Sump Gastric sump tube ( salem. Ventrole)
Double lumen catheter .clear plastic
Plastic, FR.
It is 120 cm long
Used to decompress the
stomach, keeps it empty

7. Smaller, 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.

9. Medium tubes.
Medium length- nasoenteric used for feeding. Example- Dobhoff
Placed in the duodenum or jejunum by fluoroscopy (x-ray dept) or at client’s bedside.
Verified by x-ray before feedings
begin. May take up to 24 hrs.
to pass through the stomach
into the intestines.
Place client on right side
to facilitate passage

10. Long- 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 fluid
Used to (Decompression) to prevent intestinal obstruction.
Due to  peristalsis, prevents vomiting, reduces tension at the incision line and prevents obstruction.

11. Long- nasoenteric tubes.
Examples of long tubes:
Miller- Abbott-
is double lumen ( fr ) 300 cm rubber tube
one lumen used for aspiration and other for Introduce with mercury, water, or saline

12. Long- nasoenteric tubes
Harris-
Is single lumen ( 14 fr )
used for suction and irrigation
mercury-weighted of about 180 cm
This tube metal tip that lubricate
This use for irrigation & suction .

13. Long- nasoenteric tubes
Cantor tube –
has a large balloon at distal end of tube. Filled with
4- 5 ml of mercury, water or saline to weight the tube
It is 300 cm long

14. Procedure of Inserting nasogastric tube

15. Tube inserted through the nose into stomach
Definition
Tube inserted through the nose into stomach

16. Purposes:
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 lungs
To establish a means for suctioning stomach contents to prevent gastric distention ,nausea, and vomiting.
To remove stomach contents for laboratory analysis
To lavage(wash)the stomach in case of poisoning or overdose of medications. 

17. Purposes 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.

18. Assessment & Preparations:
Assessment & Prepare the client
Presence of gag reflex
Mental status or ability to cooperate with procedure
Check 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

19. Assess the client nares
Ask client to hyperextend the head & using flashlight
Observe ( 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 other
Patency of nares & intactness of nasal tissue ( note especially history of nasal surgery or deviated septum )

20. Assess & prepare the tube
If rubber tube :
used placed it on ice for 5 to 10 minutes
This stiffens the tube , facilitating insertion
If plastic tube
Used place it in warm water until tube softer & more flexibility , facilitating insertion

21. Equipments: Nasogastric tube Adult - 16-18F Viscous lidocaine 2%
Oral analgesic spray (Benzocaine spray or other)
Oral syringe, 12 mL
Glass of water with a straw
Water-based lubricant

22. Equipments: Non allergenic adhesive Tape 2,5 cm wide
Emesis basin or plastic bag
Wall suction, set to low intermittent suction
Suction tubing and container
Flashlight .
Stethoscope.
Toomey syringe (20 to 50 ml) .
Tissues
Disposable pad & gloves . .
Tongue blade .
Normal saline solution (for irrigation only).

24. Procedure:

25. Note
A 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

26. Determine 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.

27. Nasogastric tube lubrication with water-based lubricant.

28. Estimation of nasogastric tube length from nostril to stomach

29. Insert 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 anesthetize
Lubricate tip of tube with water soluble lubricant.
Ask client to lift head, and insert tube into nostril while directing tube upward and backward.

30. Aspiration of viscous lidocaine into an oral syringe

31. insert of viscous lidocaine 2%

32. Cont,,
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.

33. Patient flexing his neck and drinking water while a nasogastric tube is inserted.

34. Advance 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.

35. Confirming Placement
Tube 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.

36. Auscultation over the stomach

37. Nasogastric tube in lung.

38. Securing 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.

39. Secured nasogastric tube.

40. Document Document: Tube type and size
Drainage or aspirate (residuals) amount, color and consistency
Irrigation type and amount
Suction- type and level (i.e. low intermittent)
Feeding- type and amount
Patient tolerance
Patient/ Family education and response

41. NG Suction
Tube 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.

42. Conte,,, Remove disposable gloves. Wash hands. Remove all equipment.
Keep the client at comfortable position.
Assist with or provide oral hygiene at regular intervals.

43. Complications The main complications of NG tube insertion :-
aspiration and tissue trauma.
Placement of the catheter can induce gagging or vomiting, Patient discomfort
Epistaxis
Pulmonary complication
Esophageal perforation

44. Contraindications Absolute contraindications
Severe mid face trauma
Recent nasal surgery
Relative contraindications
Coagulation abnormality
Esophageal varicose or stricture
Alkaline ingestion

45. Procedure of Administering a Tube Feeding.

46. Tube Feedings Meet nutritional needs when oral intake not possible
Advantageous over TPN
GI integrity is preserved
Normal insulin/glucagon ratios are maintained
Admin. intermittent, continuous
Accessed by nasogastric, nasoenteric, gastrostomy or jejunostomy tube

48. Assessment
Before a nasogastric or orogastric feeding determine type amount frequency of feeding & tolerance of previous feeding
Assessment signs of malnutrion or dehydration
Assess allergies to any food
Presence bowel sound
Any tolerance of previous feeding ( delayed gastric empty , abdominal distention . Constipation )

49. To restore or maintain nutritional status. To administer medications.
Purposes:
To restore or maintain nutritional status.
To administer medications.

50. Equipments: Feeding container.
Large syringe with plunger or calibrated plastic feeding bag with tubing or Prefilled bottle with a drip chamber tubing & flow regulator clamp
Stethoscope. Disposable gloves. Alcohol swab.
Toomey syringe 20 to 50 ml with adaptor .
Water for irrigation or normal saline.
Emesis basin
Feeding pump as required

51. Procedure:

52. Explain 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

53. Procedure 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

54. Performance:
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 temperature
Assess residual feeding content
Aspirate all stomach content & measure a mount prior to administering the feeding

55. Feeding 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.

56. Feeding 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.

57. Open 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.

58. Syringe feeding
Add 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 tube
Cover end of tube.
Observe the client's response during and after tube feeding.
Keep client in upright position for
at least 30 minutes to 1 hour after feeding.
Remove gloves. Wash hands

59. Documentation:
Record type and amount of feeding, residual amount ,and client's response, monitor blood glucose level, if ordered by physician.

60. Procedure of Irrigating Nasogastric Tube

61. To clears the tube of feeding or debris.
Purposes:
To clears the tube of feeding or debris.
To prevent the spread of microorganisms in the tube of feeding.

62. Equipments: Normal saline solution or water for irrigation.
Disposable gloves.
Stethoscope.
Toomey syringe.
Container.
Disposable pad.

63. Procedure:

64. Preparation: 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.

65. Hold 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.

66. Documentation:
Record irrigation procedure, description of drainage, and client's response.

67. Procedure of Removing a Nasogastric Tube

68. Purposes: 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.

69. Equipments: Tissues. 50-ml syringe (optional). Disposable gloves.
Disposable plastic bag.
Disposable pad.
Normal saline solution or water for irrigation (optional).
Emesis basin.

70. Procedure:

71. Preparation: 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.

72. Carefully 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.

73. (Total parental nutrition( TPN

74. Definition 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

75. Indications for TPN
Mall absorption syndromes, such as short bowel syndrome
Conditions requiring complete bowel rest for prolonged periods
Pre and post-operative support in patients with pre-existing malnutrition, in who GI function is impaired
Malignancy undergoing treatment, surgery, radiation, chemo who are unable to obtain adequate nutrition by an enteral route

76. TPN is generally NOT indicated…
When an inpatient has a functioning GI tract
TPN therapy is expected to be less than 5 days
Prognosis does not warrant aggressive nutrition support

77. Source of Nutrition Eternal nutrition Parenteral nutrition
Central parenteral nutrition (CPN=TPN)
Peripheral parenteral nutrition (PPN)
Long-term home parenteral
nutrition (HPN)

78. Clinical decision algorithm route of nutrition support
Nutrition Assessment
Decision to institute special nutrition support
YES
Functional GI Tract NO
Enteral Nutrition
Parenteral Nutrition
Short-term:
NG, ND,NJ
Long-term:
Gastrostomy Jejunostomy
GI function
PPN
TPN
Intact
Nutrients
Defined
Formula
GI function return
Adequate
Inadequate
Adequate
YES NO PN
Oral Feeding

79. Components of TPN
Carbohydrate, Amino acid, Fat, Electrolyte, Water, Vitamin, Trace element
Standard solution
Dextrose, Amino acid
Electrolyte (Na, K, Cl, Mg, Ca, P)
Vitamin (A, B1, B2, Niacin, B6, Panthothenic acid, C, D, E, Zn, Cu, Mn, Cr)
Lipid emulsion

80. Total Parenteral Nutrition
Normal Diet TPN
Protein Amino Acids
Carbohydrates Dextrose
Fat Lipid Emulsion
Vitamins Multivitamin Infusion
Minerals Electrolytes
and Trace Elements

81. complication Mechanical: thrombosis, embolism, skin slough
Infectious: particularly staph epidermidis, Candida
Metabolic: hypoglycaemia, hyperglycaemia,
cholestasis

82. Thank you
kamlya