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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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end
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