Download Chapter_044 NG TUBES REV SP 16

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
 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
9
•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
11
12
13
Chest Xray Representing a Properly placed NG tube
14
Chest xray NG tube in left main stem Bronchi
15
16
pH Measurement for Tube Location
Conti
nous
pH=1to 4 pH=5
S
Stomach
T
O
M
A
C
H
Instestine
pH=6
See Box 44-13 on text p. 1020
Securing
Device
18
Water-Soluble Lubricant
Benzocaine Spray
Viscous Lidocaine
Penlight
Penlight
Penlight
Tissues
Straw
19
Glass
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
30
31
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-SumpTubeUsually 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-DocumentDrainage
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