Gastrointestinal ion

7/31/2019 Gastrointestinal ion

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The insertion of a rubber or plastictube into the stomach, the duodenum,or the intestine.


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mouth, nose, abdominal wall

short (NGT)

medium (nasoduodenal tube)long (nasoenteric tube)


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to decompress the stomach and remove gas andfluid

to lavage the stomach and remove ingested toxins

to diagnose disorders of GI motility and otherdisorders

to administer medications and feedings

to treat an obstructionto compress a bleeding site

to aspirate gastric contents for analysis


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Sengstaken-Blakemore tube

bleeding esophageal varices

OGT removal of particles of ingestedsubstances


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The nasogastric feeding route is not suitablefor all patients, including those with:

High risk of aspiration

Gastric stasis

Gastro-oesophageal reflux

Upper gastrointestinal stricture

Nasal injuries

Base of skull fractures


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1) Providing instructions


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Measure the distance from the tip of the nose tothe earlobe, and from the earlobe to the

xiphoid process + 6inches for NG placementor 8-10 inches for intestinal placement.

upright position

towel spread bib-fashion over the chest tissue wipes privacy and adequate light

Cetacaine (tetracaine/benzocaine)

Liquid anesthetic / hold ice chips in themouth

breath through the mouth or pant

oftenSwallow water

Polyurethane tube

warmed to make it morepliable

Lubricate with KY jelly (water soluble)Hydromer - when moistened , provides its own

lubricationwear gloves

inspect nostrils fowlers position tilt tip of the nostril and tube is aligned to enter the

nostriNasopharynx : head slightly lowered and begin to swallow

as the tube is advacedCheck oropharynx to ensure that tube has not coiled in

the pharynx or mouth


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High Risks Patients:1) Dec. LOC

2) Confused mental state

3) Poor or absent gag reflex4) Agitation

5) ETT

XrayInjecting air and

Auscultation

Measurement of tubelength

Visual assessment of

aspiratepH measurement ofaspirate

Visual Assessment of theCOLOR

1) gastric cloudy and

green, tan or off- whiteor bloody or brown

2) Intestinal clear andyellow to bile-colored

3) Pleural fluid

paleyellow or off-whitemucus

pH Measurement1) Gastric

acidic (1-5)

2) Intestinal 6 orgreater

3) Respiratory 7 orgreater


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Pyloric sphincter - 5-6cm (2-3inch) q hr

R side for 2hrs, back for 2hrs, L side 2hrs

Ambulation

Irrigate c NSS q 6-8hrs to prevent blockade Too rapid: curing and kinking of tube


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Decompression

attached to intermittent low suction

Enteral nutrition end of the tube is plugged betweenfeedings

Confirm tube placement before any meds and fluidsare instilled

MIO

Irrigate tube q 4-6 hrs c NSS

Assess amount, color, and type of drainage q 8hrs Double/triple lumen tubes : amount, color, type of

drainage


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moistened cotton-tipped swabs

Water soluble lubricant

Mouth care

nasal tape 2-3 days Inspect nose for irritation

Throat lozenges, ice collar, chewing gum, sucking onhard candies

Frequent movement


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FVD Dry skin and mucous membrane

Dec. urine output

Lethargy Dec. BT

MIO

BUN, creatinine


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Pulmonary Complications impaired coughing and clearing of the pharynx

meds (antacids, siethicone, metoclopramide)

s/s: coughing during administration of foods and

meds

difficulty clearing the airwayTachypneaFever


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Irritation of Mucous Membrane Nostrils, oral mucosa, esophagus, trachea

irritation

Dryness

Enlarged nodes around parotid glands

Sorethroat

hoarseness


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Intermittently lamp and unclamp the NG tube for24hrs Nausea and vomiting, distention

Flush c 10ml of NSS

Deflate balloon Wear gloves w/draw tube gently and slowly for 15-20 cm (6-

8inch) Nasoenteral tube: interval of 10 minutes Force should not be used /report to POD Tube removed should be concealed w/ towel Mouth care


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Advantages Low in cost

Safe

Well tolerated by the patient

Easy to use

Preserve

GI integrity

Maintain fat metabolism and lipoproteins synthesis

Maintain normal insulin/glucagon ratios


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NGT, gastrostomy

stomach

nasojejunal , nasodoudenal distal doudenum,proximal jejunum Bypass esophagus, stomach

Risk for aspiration

Long term feedings

1. Nasodoudenal2. Gastrostomy

3. Jejunostomy


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Fluid balance is maintained by S

Osmosis

process by which water movesthrough membranes from a dilute solution oflower osmolality to a more concentrated

solution of higher osmolality until bothsolutions are of nearly equal osmolality,

Small particles that have great osmotic effects:

amino acids CHO

Electrolytes (Na, K)

High osmolality solution

fluid shifts to the stomach and intestines

Feeling of fullness, nausea, diarrhea

DHN, hypotension, tachycardia

DUMPING SYNDROME


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Status of the GI tract

Nutritional needsCharacteristics :1. Chemical composition of the nutrient source2. Caloric density3. Osmolality4. Residue5. Bacteriologic safety

6. Vitamins7. minerals8. Cost


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Silastic nasoenteric tube

Intermittent bolus feedings (gastrostomytube) stomach

Continuous

small intestine (pump)

Dec. abdl distention, gastric residuals, riskfor aspiration

cyclic feeding

faster rate over a shortertime


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Temp

Volume of the feeding

Flow rate

Total fluid intake

Schedule of tube feedings: correctquantity, frequency

avoid administering fluids too rapidly


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1. Gravity (drip) placed above the level of the stomach, with the

speed of administration determined by gravity.


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2. Bolus feedings given in large volumes (300-400ml q 4-6hrs)


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3. Continuous feedings preferred method =) delivery of the feeding in small

amounts over long periods reduces theincidence ______, _______, ____, _____

100-150mL/hr (2400-300 cal/day)

Nitrogen positive balance, wt gain w/oabdl cramps and diarrhea


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4. Intermittent feeding 200-350ml is given in 10-15mins

Enteral pumps control the delivery rate and can

infuse a viscous formula through a small-diameterfeeding tube

Measure residual content before each intermittentfeeding and q 4-8hrs for cont. feeding Readminister


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Tube feeding intolerance

Aspirated gastric content :

200ml or greater for NGT

100ml or greater for gastrostomy tubes cont. tube feeding

radigraph studies

physical status

If excessive residualvolumes occur TWICE,

the nurse notifies the

physician!!!


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Goal: to ensure patency and to decrease the chance ofbacterial growth, crusting, or occlusion of the tube, 20-30ml of water is administered in each of the following

instances:

1) before and after each dose of

medication and each tube feeding2) after checking for gastric residualsand gastric pH

3) Q 4-6hrs c cont. feedings4) If the tube feeding is DC for any

reason


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each meds is given separately using bolus method

Tube is f lushed c 20-30ml of water after each dose

Crushed tabs and dissolve c water

Do not mix meds with each other or with feedingformula

small bore feeding tubes for cont feeding infusion areirrigated after meds administration, 30ml or larger

syringe is used.


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Diarrhea

formulas have little or no residue

1. Dumping syndrome

2. Zinc dif. -15mg of zinc q 24hrs (50-150fg/dL)3. Contaminated formula

4. Malnutrition

5. Medication (clindamycin, lincomycin,quinidine, propranolol, aminophylline ,theophylline, digitalis

Dumping syndrome results from rapiddistention of jejunum with hyperonicsolution are administered quickly over

10-20ml/min


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established tube placement correctly beforefeeding , each med is administered, once qshift

Semi fowlers position and maintained in1hr after intermittent feeding and all thetime for cont feeding

Monitor residual volumes

Aspiration: stop feeding immediatelySuction pharynx and tracheaPlace patient on the right side with thehead of bed downNotify physician


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Water at least 2L/day q 4-6hrs and after feeding

At the beginning of the administration, the feeding isdiluted to at least haf-strength and not more than 50-100ml is given at a tie, or 40-60mL/hr I given in a contfeeding

Monitor for s/s of DHN

MIO

Administer fluid routinely


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Slow the formula instillation rate to provide time forCHO and E to be diluted

Administer feeding at room temperature, becausetemp extremes stimulate peristalsis

Administer feeding by cont drip rather than by bolusto prevent sudden distention of the intestine

Remain in semi fowlers position

Instill minimal amount of after needed to flush thetubing before and after feeding, because fluid givenwith a feeding increases intestinal transit time


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Personal protective equipmentNG/OG tube

Catheter tip irrigation 60ml syringeWater-soluble lubricant, preferably 2% Xylocaine jelly

Adhesive tapeLow powered suction device OR Drainage bag

StethoscopeCup of water (if necessary)/ ice chips

Emesis basinpH indicator strips


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1. Explain the procedure andobtain consent

2. Provide a signal for thepatient to stop theprocedure

3. Sit the patient in a semi-upright position with thehead supported with pillowsand tilted neither backwardsnor forwards


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Examine the nostrils for deformity or obstructions todetermine the best side for insertion

Measure the tubing from the bridge of the nose to theearlobe, then to the point halfway between the lowerend of the sternum and the navel

Mark the measured length with a marker or note thedistance

Lubricate 2-4 inches of tube with lubricant (e.g. 2%Xylocaine)


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Pass the tube via either nostril, past the pharynx, intothe oesophagus and then into the stomach

Instruct the patient to swallow and advance the tube asthe patient swallows (sipping a glass of water helps)

If resistance is met, rotate the tube slowly whileadvancing downwards. Do not force

Stop immediately and withdraw the tube if patient

becomes distressed, starts gasping or coughing,becomes cyanosed or if the tube coils in the mouth


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Advance tube until mark isreached

Check for placement by attaching

syringe to free end of the tube,aspirate sample of gastriccontents. Do not inject an airbolus, as the best practice is to test

the pH of the aspirated contentsto ensure that the contents areacidic. The pH should be below 6.Obtain an x-ray to verify

placement before instilling anyfeedings/medications or if youhave concerns about theplacement of the tube.


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Secure tube with tape or commercially prepared tubeholder

If for suction, remove syringe from free end of tube;connect to suction; set machine on type of suction andpressure as prescribed.

Document the reason for the tube insertion, type &size of tube, the nature and amount of aspirate, thetype of suction and pressure setting if for suction, thenature and amount of drainage, and the effectivenessof the intervention.


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- Partially pre-freezing the tube can ease its passage.

- Infants can suck on a pacifier during the procedure.

- Dont rely on a cuffed endotracheal tube to prevent

passage into the trachea be sure and confirm placement

using the above methods.


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Do not use force when inserting a NG tube. Ifresistance occurs, rotate and retract the tube slightlyand try again. Forcing the tube can cause traumaticinjury to the tissue of the nose, throat or esophagus.

Always check the tube positioning before givingfeedings. If the tube is out of place the patient mayaspirate the feeding solution into the lungs.


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Keep the patient in an upright or semi-upright sittingposition when delivering a tube feeding to enhanceperistalsis and avoid regurgitation of the feeding.

Check patients who are receiving continuous feedings

via a pump or gravity hourly or according to themedical settings policy, to assure that the tube is inposition, the formula is flowing at the correct rate andthe patient is comfortable with no signs of distentionor distress.

Cap or clamp off the NG tube when not in use toprevent backflow of stomach contents oraccumulation of air in the stomach.


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If a patient has severe sinus conditions, nasalobstruction or has had facial surgery, it may benecessary to place a oral-gastric tube to avoid furthernasal trauma.


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If the amount of gastric aspirate is large prior to abolus or intermittent feeding, notify the physician andfollow the protocol of the medical setting for re-instilling the gastric aspirate. The feeding size may

need to be decreased if the patient is not digesting it.


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If the amount of gastric aspirate is large prior to abolus or intermittent feeding, notify the physician andfollow the protocol of the medical setting for re-instilling the gastric aspirate. The feeding size may

need to be decreased if the patient is not digesting it.


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NG tube placement is meant to be a short-termsolution for feeding problems. Patients that requirelong term tube feeding should have surgical placementof a gastrostomy tube or gastrostomy button. Long-

term NG tube usage can cause nasal erosion, sinusitis,esophagitis, gastric ulceration, esophageal-trachealfistula formation, oral infections and respiratoryinfections.


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stop advancing the tube and allow the

patient to rest.


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retract the tubing and try again


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advance the tube between respirations to avoid placingthe tube into the trachea


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remove the tubing, allow the patient to restand begin again.


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the tube has passed through the vocal

cords and into the trachea. Remove thetube and start again.


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use a flashlight to look into the patient's

mouth to view the tubing. It should appearstraight in the back of the throat with nocoiling into the mouth.


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x ray of the abdomen


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Aspirate the stomach contents for residualformula from the last feeding. If the residual

exceeds 100 cc for an adult, hold the feedingand notify the physician.

Re-instill the gastric aspirate according to

the policy of the medical center or thephysician's order. Review the physician'sorder and select the appropriate type andamount of feeding.

Be sure that the patient remains in anupright position during the feeding.


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Shake prepared formulas beforeadministering them. Formulas that havebeen refrigerated should be allowed to warm

up to room temperature beforeadministering them.

To give the feeding using a syringe, remove

the barrel from the syringe.


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Open the end of the NG tube and connect itto the end of the syringe. Pour the feeding

into the wide end of the syringe and hold orsecure the syringe to the bed or an IV polejust above the patient's head so that it will

flow in slowly by gravity over 15-30 minutes. If more feeding is needed than can be held

in the syringe, watch the syringe and refill

the syringe until the feeding is complete.When the feeding is complete, rinse thetube with 30 cc of water.

Di t d th d f th NG


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Disconnect and recap the end of the NGtube and rinse the syringe according to the

medical setting's policy. To give anintermittent feeding using a feeding bag,pour the correct feeding amount into thebag and through the tubing connected tothe bag down to the tip of the tubing.

Clamp the tubing using the roller clampapparatus. Hang the bag on an IV pole just

above the patient's head. Open the NG tubeand connect it to the feeding bag tubing.


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Gastrointestinal ion

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