1. Gastro-Intestinal Tubes & Enteral Nutrition
NURS 108
Majuvy L.Sulse MSN, CCRN

2. Enteral Feeding Nutrients given via the GI tract
Easier to give especially for home care
Types:
Polymeric-1 to 2kcal/ml-milk based blenderized foods prepared by the dietary or at home
Modular-3.8 to 4kcal/ml-single and incomplete formulas
Elemental-1 to 3kcla/ml predigested nutrient formulas for a partially functional GI to absorb
Specialty formulas-1 to 2 kcal/ml-formulas designed to meet specific needs in certain illness.

3. Feeding Tubes
Nasoenteric tubes (NET)- usually for short term <4 weeks
Nasogastric (NGT)-
Nasointestinal-doudenal or jejunal (NDT/NJT)
Surgically placed (enterostomal) gastrostomy & Jejunostomy tubes-long term use
Endoscopic
gastrostomy (PEG)
Jejunostomy (PEJ)-bypass stomach in presence of gastric disease, UGI obstruction, abnormal gastric or doudenal emptying

4. Feeding Tubes
Nasointestinal tubes are longer than NG tubes and are indicated to medically treat an obstruction of the small intestine in someone who's a very poor surgical risk. They rely on a weighted distal end and peristalsis to advance the tube along the intestinal tract in an attempt to relieve the obstruction

5. Feeding tubes

6. Indications for Enteral feedings
Inadequate oral intake
Continuous feedings
CVA
Difficulty swallowing-absence of gag reflex
Anorexia Nervosa
Severe depression
Local trauma or critical illness
Prolonged intubation
Gastrointestinal disorders
Fistulas, IBD, mild pancreatitis

7. Indications for Enteral feedings
Neurological and mascular disorders
Brain neoplasm
CVA
Dementia
Myopathy
Parkinson’s disease
Cancer
Upper GI
Head & Neck

8. Nursing Management Patient position HOB 30-45 degrees Patency of tube
Irrigate with water before and after each feeding (if intermittent) or medication administration
Tube position
Check tube placement before each feeding and drug administration
Xray –most accurate assessment of placement
Aspirate gastric contents
Check pH contents-less than 5 indicative of stomach contents
Check every 4-8 hours with continuous feedings
Check for bowel sounds

9. Nursing Management Formula Given at room temperature
Amount in bag should not exceed 4 hours or per policy
Labeled with date and time initially used
Aspirate contents & measure amount-if volume is >200 ml with signs of intolerance, hold feeding for an hour and recheck residual volume. Aspirate should be re-instilled.

10. Nursing Management
Feeding administration-rate & volume increased gradually to minimize side effect as nausea & diarrhea. Water flushes or boluses given
Feeding pump-continuous
Gravity method-intermittent-volume is usually /feeding
Nursing care
Daily weights or as per policy
I/O
Blood glucose
Oral care

11. Complications related to Tube Feedings
Vomiting or aspiration
Improper tube placement
Delayed gastric emptying
Contamination of formula
Diarrhea
Feeding too fast, hypertonic formula, medications
Lactose intolerance
Low fiber formula

12. Complications related to Tube Feedings
Constipation
Formula components
Poor fluid intake
Drugs
Impaction
Dehydration
Excessive diarrhea
Hyperosmotic diuresis
High protein formula

13. Nursing diagnosis Imbalance nutrition: less than body requirements
Weight monitoring to make caloric adjustment
Progress slowly to avoid gastric distention
Gradually add high calorie foods to maintain weight
Impaired skin integrity related to enzymatic action of gastric juices
Assess skin daily for signs & symptoms of irritation
Apply protective skin barrier
Strict handwashing
Patient & family teaching

14. Nursing diagnosis Risk for aspiration Positioning
Aspirate gastric contents before feeding
Disturbed body image related to presence of feeding tube
Encourage expression of feelings
Acknowledge patient fears
Provide correct information

15. Nursing diagnosis Risk for deficient fluid volume/volume overload
Monitor mucous membranes & skin turgor, VS, I/O
Provide adequate fluid intake
Reinstill gastric contents to prevent electrolyte losses
Ineffective therapeutic regimen management
Give detailed information and return demonstration techniques to validate learning

16. Legal & Ethical Issues
Withholding food & fluids-what happens if clients are not able to make decisions or make their wishes known????
Review what is known about tube feedings especially risks & benefits
Review medical facts about the client
Obtain the opinion of all stakeholders in this situation
Delay any action until consensus is achieved

17. Decompression Tubes
Occasionally, a tube can be used for acute treatment of active bleeding from esophageal or gastric varices. Two types are most common:
* The Sengstaken-Blakemore tube has a large balloon to compress the esophagus and a smaller one to anchor the tube and exert pressure against varices in the distal esophagus and the cardia of the stomach. It has three lumens-one each to inflate the balloons and one attached to suction to aspirate gastric contents. To suction secretions above the esophageal balloon, an additional tube, such as a Salem sump tube, is placed in the proximal esophagus.
* The Minnesota tube is similar to the Sengstaken-- Blakemore tube, but it also has an esophageal aspiration lumen that eliminates the need for an additional drainage tube.

19. Decompression Tubes
Gastric tubes-commonly used NG tubes that are placed for GI decompression or drainage..
Salem sump- The Salem sump has two lumens, one for drainage and one for air. The drainage lumen is usually connected to low continuous suction. At times, however, higher levels may be needed. The air vent keeps the tube away from the stomach wall to prevent damage to the mucosa
The single-lumen Levin tube is typically connected to intermittent low suction for the same purpose.

20. Decompression Tubes
Intestinal Tubes mercury-filled balloon at the distal end. These tubes are rarely used today because the balloon could rupture and leak mercury. The newer Andersen tube, with a pre-weighted tungsten tip, is a safer option
Miller Abbot tube-A long 10’ (3 m) double-channel intestinal tube. Inserted through a nostril, the tube is passed through the stomach into the small intestine. Used for sampling gastrointestinal fluid or for therapeutic aspiration to relieve intestinal distension.
Cantor tube- 10’ single-lumen tube with a suction port in the lumen to aspirate contents
Harris Tube- short around 6’single lumen also to relieve distention, Y end allows lavage of intestinal tract
Dennis tube-10’ 3 lumen: irrigation, drainage & balloon inflation

21. Andersen tubes