Transcript Intestinal Decompression Tube

Chapter 29
Gastrointestinal Intubation
Objectives
0 1. Define intubation and list reasons for gastrointestinal intubation.
0 2. Identify four general types of gastrointestinal tubes.
0 3. Name at least four assessments that are necessary before
0
0
0
0
0
0
0
inserting a tube nasally.
4. Explain the purpose of and how to obtain a NEX measurement.
5. Describe three techniques for checking distal placement in the
stomach.
6. Discuss three ways that nasointestinal feeding tubes or their
insertion differ from their gastric counterparts.
7. Name four schedules for administering tube feedings.
8. Explain the purpose of assessing gastric residual.
9. Name five nursing activities involved in managing the care of
clients who are being tube-fed.
10. Name two nursing responsibilities for assisting with the
insertion of a tungsten-weighted intestinal decompression tube.
Intubation
Reduces/eliminates problems associated with
surgery or conditions affecting the GI tract
Impaired peristalsis
Vomiting
Gas accumulation
Provide nourishment to clients not able to eat.
Intubation
Intubation: placement of a tube into a body
structure
Types of intubation
Orogastric: mouth to stomach
Nasogastric: nose to stomach
Nasointestinal: nose to intestine
Ostomy: surgically created opening
Nasogastric Tube
Vented Nasogastric Tube (Salem Sump)
Question
Is the following statement true or false?
Orogastric intubation is the insertion of a
tube through the nose into the stomach.
Intubation
Gastric or intestinal tube uses include:
Performing gavage (providing
nourishment)
Administering oral medications
Sampling sections for diagnostics
Intubation
Performing a lavage (removing
substances from the stomach;
poisons)
Compression/decompression
(removing gas & liquids from
stomach/bowel)
Gastrointestinal Tubes
Orogastric tubes (Ewald tube):
Used in emergency to remove toxic
substances
Diameter is large enough to remove pill
fragments & stomach debris
Nasogastric Tubes
Some have more than one lumen
(channel) within the tube
Levin tube is commonly used
because it has multiple purposes:
Lavage, Gavage, Decompression,
Diagnostics
Nasogastric Tubes
Gastric sump tubes (double-lumens):
Used almost exclusively to remove fluid and
gas from the stomach
2nd lumen serves as a vent
Use of sump tubes decreases the possibility
the stomach wall will adhere to and obstruct
the drainage openings when suction applied
is applied
Nasogastric Tubes
Common complaint from clients is nose and
throat pain
If tube’s diameter is too large/pressure from
the tube is prolonged, tissue
irritation/breakdown may occur
Tend to dilate the esophageal sphincter which
can contribute to gastric reflux
If reflux occurs, liquid could enter the airway
Nasointestinal Tubes
Longer than nasogastric tubes inserted
through the nose for distal placement below
the stomach
Almost all have a weighted tip to help tube
descend past the stomach
Added length allows placement in the small
bowel
Used for feeding or decompression
Nasointestinal Tubes
Pros:
Narrow width and soft composition allow
them to remain in the same nostril for
approximately 4 weeks
Reduce the potential for gastric reflux because
deliver nutrition beyond the stomach
Nasointestinal Tubes
Cons:
So flexible tend to curl during insertion
Checking placement more difficult
Become obstructed more easily
Preferred for the client comfort, ideal for
continuous infusion of nourishment.
Nasointestinal Tubes
Intestinal decompression: removal of gas and
intestinal contents
Used for partial/complete bowel
obstruction
Has a double lumen and weighted tip. One
lumen used to suction, the other acts as a
vent reducing suction-induced trauma to
intestinal tissue.
Nasointestinal Tubes
Intestinal decompression
Weighted tip & peristalsis, if present,
propels tube beyond stomach
Progress of the radiopaque tip through the GI
tract is monitored by X-ray.
Transabdominal Tubes
Transabdominal Tubes are placed through
the abdominal wall providing access to
various parts of the GI tract.
Gastrostomy tube: located within the
stomach
Jejunostomy tube: leads to the jejunum of
small intestine
Transabdominal Tubes
Percutaneous endoscopic gastrostomy (PEG):
inserted under endoscopic guidance anchored
with internal and external crossbars called
bumpers
Percutaneous endoscopic jejunostomy (PEJ):
small in diameter & passes through the PEG
tube into the jejunum
Transabdominal Tubes
Transabdominal tubes are used instead
of nasogastric or nasointestinal tubes
when clients require an alternative to
oral feeding for more than 1 month.
Q-1
Question
Is the following statement true or false?
A nasointestinal tube is a tube placed
through the nose and advanced to the
stomach.
Answer
False.
A nasointestinal tube is inserted through the
nose for distal placement below the stomach.
Types of Gastrointestinal Tubes
p.637
Nasogastric Tube Management
Pre-Insertion assessments:
Level of consciousness; weight
Bowel sounds; abdominal distention
Nasal/oral mucosa integrity
Swallow, cough, gag ability
Nausea or vomiting present
Question
Is the following statement true or false?
Assessing abdominal distention is part of
preintubation assessment conducted by the
nurse.
Answer
True.
Assessing abdominal distention is part of
preintubation assessment conducted by the
nurse.
Tube Measurement and Placement
NEX measurement
Length from nose to earlobe to xiphoid
process, marking tubing for reference
Tube Measurement and Placement
Nurse’s Primary Concerns are:
Locate tube within the stomach, not the
respiratory passages
Insertion should cause as little discomfort as
possible
Preserve integrity of nasal tissue
Keeping the tube patent
Tube Placement and Measurement
Determine proper placement using:
Fluid aspiration inspection
o Visual inspection
o pH testing
o Abdominal auscultation
o Abdominal x-ray (by MD order)
Obtaining the NEX Measurement
Before inserting: Nose to Earlobe to the Xiphoid process (tip of the sternum).
Aspirating to Assess pH
pH Testing
Assessing the pH of Aspirated Fluid
Q-2
Nasogastric Tube Management
Gastric decompression
Suction continuously or intermittently
o Vented tubing protects stomach mucosa
Promote/restore patency
o Administer ice chips or sips of water sparingly
o Irrigation (by physician order only if this is the
agency policy)
p.656
Intestinal Decompression Tube
A. Including the suction lumen, B. Vent lumen
C. Openings for suction, D. Radiopaque tungston tip
Inserting a Nasogastric Tube
(Refer to Skill 29-1 in the textbook.)
Nasointestinal Tube Management
Insertion of nasointestinal tubes
NEX measurement + 9 inches
Checking tube placement
Initially via x-ray
Subsequently, modified aspiration with large
volume syringe (50 ml)
Inserting a Nasointestinal Feeding Tube
Refer to Nursing Guidelines 29-2
p. 642
Stylet Used to Keep Tube from Curling
Figure 29-11:
Removing a stylet
NGT: Client Preparation
Decrease client anxiety: suggesting diameter
of tube is smaller than most food
Explaining procedure; giving clear
instructions
Establishing a signal client can give when
needing a pause (hand raise)
Inspect nostril size, shape, patency
Transabdominal Tube Management
The nurse’s responsibility is to care for
inserted gastrostomy and jejunostomy tubes
and their insertion sites
Conscientious care is necessary to prevent
leakage and skin breakdown
G-tubes
A. Inspects for drainage, B. Inspects the skin
A. Percutaneous endoscopic gastrostomy (PEG) tube
B. Percutaneous endoscopic jejunostomy (PEJ) tube
Causes of Gastrostomy Leaks
Tube disconnection or clamped during
feeding
Mismatched size of G-tube and stoma
Increased abd pressure: formula
accumulation, retching, sneezing, coughing
Underinflation of the balloon
Unfavorable stoma or stomal location
Comparison of Feeding Tubes
Tube Feedings
Enteral nutrition is provided via stomach or small
intestine rather than oral route
Benefits and risks
oUses body’s natural reservoir for food
oReduces potential for enteritis
oIncreases risk for gastric reflux
oDumping syndrome (rapid gastric emtying) for
intestinally placed tubes
Question
Which of the following are symptoms of the
dumping syndrome? Select all that apply.
a. Sweating
b. Appetite loss
c. Weakness
d. Nausea
Answer
a. Sweating, c. Weakness, d. Nausea
The symptoms of dumping syndrome are weakness,
dizziness, sweating, and nausea, due to fluid shifts
from the circulating blood to the intestine, and low
blood glucose level related to a surge of insulin.
Appetite loss is not a symptom of the dumping
syndrome.
Formula Considerations
Formula type based on client’s nutritional
needs
o Factors affecting formula types are:
Weight, nutritional status, concurrent
medical conditions and length of therapy
Feeding schedule: concentrated calories for
those being fed several times a day
Tube-Feeding Formula Type
Description
Standard, isotonic
Routine formulas for clients with normal
digestion and absorption; do not alter water
distribution.
High calorie
Provide up to double the amount of calories
of standard formulas for clients who require
a fluid restriction or have high calorie needs
High protein
Provide up to double the amount of protein
of standard formulas
Fiber containing
Provide fiber to normalize bowel function in
clients with diarrhea or constipation
Partially hydrolyzed
Provide nutrients in simple form that
require little or no digestion for clients with
impaired digestion or absorption
Tube Feedings
Tube-feeding schedules
Bolus feedings
Intermittent feedings
Cyclic feedings
Continuous feedings
Bolus Feedings
250-400mL formula per administration
Least desirable: distends stomach
leading to discomfort and increased risk
for reflux
Unconscious clients/those with delayed
gastric emptying are at > risk for
regurgitation, vomiting, aspiration
Intermittent Feedings
Given over 30-60 min
240-400 mL per administration
Usually given by gravity drip
Gradual filling of the stomach
Container and tube requires thorough
flushing
Cyclic Feedings
Followed by 12 hour pause between feedings,
given over 8-12 hours
Used to wean clients while maintaining
nutrition
Given late evening and during sleep
Clients still eat food during day
As food intake increases the feeding decreases
Continuous Feedings
Rate approx. 1.5 mL/min with feeding
pump
Can be delivered directly into small
intestine reducing risk of aspiration or
vomiting
Pump goes where client goes
Client Assessment
Daily client assessment: weight, vital signs,
intake/output, bowel sounds, lung sounds, breathing,
mucosal condition, etc.
Regular gastric residual assessment (volume of
liquid within stomach)
Measurement done to determine whether
rate/volume of feeding exceeds client’s
physiologic capacity
Residual: no more than 100 mL or no more than
20% of previous hour’s TF
Client Assessment
If gastric residual is high, feeding is stopped
and gastric residual is checked every 30
min until it is within a safe volume for
resuming the feeding
Checking Gastric Residual
Client Assessment
Nursing management
Maintain tube patency
Clear obstructions
Provide adequate hydration
Ready client for home care
Address miscellaneous problems
Maintain Tube Patency
Feeding tubes smaller than 12F are -prone to
obstruction
Flush feedings with 30-60 mL of water
immediately pre and post feeds/meds
Flushing q 4 hrs if client is being continuously
fed and after refeeding the gastric residual
Flushing: tap water, cranberry juice, soda
Causes of TF Obstruction
Using formulas with large-molecule nutrients
Refeeding partially digested gastric residual
Administering formula rate < 50mL
Instilling crushed or hydrophilic (waterabsorbing) meds
Clearing an Obstructed Feeding Tube
Clearing an Obstructed Feeding Tube
If obstruction occurs, MD is notified
Order is given for meat tenderizer or
pancreatic enzyme
The best noninvasive means of unclogging
tubes: Pancreatic enzymes and water
If block cannot be cleared, tube is removed and
another is placed
Providing Adequate Hydration
Tube feeding are approx. 80% water
Clients usually require additional water
Adults: 30mL of water/kg of body wt
Add water to flush per formula label
Increase volume/frequency of flushing the
tube
Monitor I/O’s
Problem
Diarrhea
Common Causes
Solutions
Common Tube-Feeding
Problems
Highly concentrated formula
Rapid administration
N/V
Rapid feeding
Overfeeding
Dilute initial tube feeding to
1/4 to 1/2 strength. Start at
25mL and increase 25mL q
12 hrs. Hang no more than 4
hrs. worth of formula.
Delay feeding until residual
is <100mL or <20% of hrly
volume.
Air in stomach
Aspiration
Incorrect tube placement
Vomiting
Dry oral and nasal mucous
membranes
Mouth breathing
Check placement before
feeding
Keep HOB elevated at least
30° during feedings and
30min after feedings
Provided frequent oral and
nasal hygiene
Dried nasal mucous
p. 648
Intestinal Decompression
Intestinal decompression: tubing introduced
into the intestines to decompress in an
attempt to avoid surgery, done with a
tungsten-weighted tube
Nursing responsibilities may include:
Tube insertion; done same way as NG tube
Intestinal Decompression
Nurse monitors the tube’s progression
In the presence of peristalsis, weight of the
tungston propels tip beyond stomach
Make a gauze sling and tape to the forehead
Placement is confirmed via X-ray
Intestinal Decompression
See Nursing Guidelines 29-6
Inserting an Intestinal Decompression
Tube
p. 649
Inserting an Intestinal Decompression Tube
Sling Made from Gauze
The sling supports the tube as it advances through
the stomach.
Removal of Intestinal Decompression Tube
Removal of intestinal decompression tube
o Performed slowly due to going through
the curves of the intestine and valves of
the lower and upper ends of the stomach
o Done in steps: withdrawing 6-10 inches
at 10-minute intervals
Removal of Intestinal Decompression Tube
When last 18 in. remains, tube is gently pulled
through the nose
Tube cannot be removed nasally if the distal
end descends below the ileocecal valve
between the small and large intestine.
Proximal end is cut; tube is removed
manually or by peristalsis through the anus.
The small intestine is the portion of the digestive system most responsible for absorption of nutrients from food into the
bloodstream. The pyloric sphincter governs the passage of partly digested food from the stomach into the duodenum. This short
first portion of the small intestine is followed by the jejunum and the ileum. The ileocecal valve of the ileum passes digested
material into the large intestine.
Nursing Implications
Potential nursing diagnoses:
Impaired swallowing and oral mucous
membranes
Imbalanced nutrition: less than body
requirements
Risk for aspiration
Diarrhea
Constipation
General Gerontologic Considerations
Diminished efficiency of the gag reflex
Precautions when tube feeding older adults related
to hyperglycemia, hydration and electrolyte
imbalance
Tailor formula specifically to client condition
Monitor older adults for agitation, confusion
resulting in pulling tubes; change in mental status
can signal electrolyte imbalance
Question
Is the following statement true or false?
Older adults may develop hyperglycemia when
tube feedings are administered.
Answer
True.
Older adults are at increased risk for fluid and
electrolyte disturbances and, as a result, may develop
hyperglycemia (elevated blood glucose levels) when
tube feedings are administered.
General Gerontologic Considerations
When instructing older adults or older
caregivers in managing gastrostomy tube or
administering tube feedings at home, allow
more time for processing and include several
practice sessions
Older adults receiving tube feeding with fullstrength formula, do fingersticks q 4 hrs for 48
hr period
General Gerontologic
Considerations
Ethical considerations of long-term tube
feedings versus client’s desire to withdraw
artificial nutrition and hydration
Checking Residual
Anchoring an NG Tube
Anchored NGT
Q-3