Chapter 44 Nutrition NasoGastric Tubes Revised ATI Skill

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

Objectives: Nasogastric 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. NG Tubes 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. 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 Enteral (TPN) bowel disease nutrition (EN); total parenteral nutrition

Assessment Screening a patient is a quick method of identifying malnutrition or risk of malnutrition using sample tools: Height Weight change Primary diagnosis Comorbidities Screening tools

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 overthe-counter (OTC) drugs; and the patient’s general nutrition knowledge Physical examination Dysphagia (difficulty swallowing)

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

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

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

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• 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.

NG TUBE INSERTION Ear lobe to xiphoid process Ear lobe to Nose Tip Ear lobe to nose tip 11

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Chest Xray Representing a Properly placed NG tube 14

Chest xray NG tube in left main stem Bronchi 15

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p. H Measurement for Tube Location Conti nous p. H=1 to 4 p. H=5 S Stomach T O M A C H Instestine p. H=6 See Box 44 -13 on text p. 1020

Securing Device 18

Water-Soluble Lubricant Benzocaine Spray Viscous Lidocaine Penlight Tissues Glass Straw 19 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. 20

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. 21

Levin Tube-Usually for feedings 22

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 23

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.

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

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.

Anyone ready for repairs? 27

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. 28

The Miller-Abbott Tube (Active Gastric Hemorrhage) 29

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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. 32

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. 33

The Salem-Sump Tube Salem-Sump. Tube. Usually for Decompression, Medications, Feedings 34

Anti-reflux valve 35

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. 36

Suction Canister-Document. Drainage 37

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) 38

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]. 39

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. 40

Mechanisms of postoperative gastrointestinal discomfort 41

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. 42

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. 43

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. 44

Questions? ? ? Thank You. 45