Fundamentals of Nursing Care,Bueron & Ludwig, Ch 24

1Fundamentals of Nursing Care, Burton & Ludwig, 2nd ed., Ch 24 & accompanying workbook.Objectives1. Identify the indications for use of enteral & parenteral nutrition.2. Compare various NG & nasointestinal tubes & their use.3. Explain what is meant by gastric decompression.4. Describe potential complications associated with tube feedings.5. Review nursing responsibilities in the management of pts receiving enteral nutrition.Enteral Feedings112In the laboratory setting, the student will be able to:check for tube placement aspirate for stomach contents- residualadminister a tube feeding by intermittent bolus flush a tube before & after administering feedingDocument findings22Terms Dysphagia: Difficulty swallowingGastric decompression: The process of reducing the pressure within the stomach by emptying it of its contents, including ingested food & liquids, gastric juices, & gasEnteral nutrition: Delivers nutrition via the GI tract34Enteral nutrition (tube feeding)Refers to the delivery of liquid nutrition into the upper intestinal tract via a tubeTube feeding may be used in addition to or instead of oral intakeIs the preferred method over parenteral (IV), because it reduces the incidence of sepsis44Purposes of Enteral TubesDecompress the stomach postoperatively, following abdominal injuryTreat intestinal obstructionProvide nutritional support or medication administrationCollect a specimen of stomach contents for diagnostic assessment of the GI tract5Types of Enteral TubesDouble lumenSalem sump tubeSingle lumenLevine tube

67Types of Enteral Tubes:Nasogastric tube(NGT) -through nose into the stomachNasoenteric tube (NE) -through the nose into the small intestine (duodenum, jejunum)Gastrostomy tube (GT)-through the abdomen into the stomachJejunostomy tube (JT)- through the abdomen into the jejunum

78NGT. Nursing care Insertion- Elevate head of bed 30-90 degreesChecking tube placementAdministration of feedingIrrigation- usually 30-60 mL NS (in I&O)Removal

Tube placement should always be checked prior or feeding. Serious respiratory complications will occur if placed into the lungs889NGT. Nursing care contdTube placement should always be checked prior or feeding. Serious respiratory complications will occur if placed into the lungs9910A danger with all enteral tubes is that they might move out of the stomach or intestine & end up in the respiratory tract101011How do you know if the tube is in the right place?NG & NE tubes are placed without direct visualization, therefore.You need to check the location of the tip of the feeding tube before infusing an enteral feedingImportant to confirm that tube has not migrated into respiratory tract111112Checking placementMost reliable method for checking placement is an x-ray, however this is usually only done after the initial placement of the tubeAn X-ray is the only way to POSITIVELY confirm any tube placement121213Checking placement contdAspirate contents- Pull back on plunger until you feel resistance. The presence of aspirant (fluid) indicates that tube is probably in the stomach. The aspirant should be greenish-brown(stomach), or the same color as the formula. Check pH. Note the amount of aspirant (residual) & replace if normal. 131314Checking placement contdRemember..You should not attempt to aspirate from a Jejunostomy-tube or Keofeed tube

Why???1414Nursing Responsibilities for NG Tube to SuctionAssess tube every 2 to 4 hrs for patencyIrrigate clogged tube according to physicians instructionsMonitor vacuum source settingAssess tubing connections & color, amount, & consistency of gastric drainageAssess positioning of tubingAuscultate bowel sounds every 4 hours

15Nursing Responsibilities for NG Tube to Suction (cont.)Assess abdomen for distentionAssess patient for adverse effects every 2 hoursAssess for passage of rectal flatusProvide mouth care every 2 hours & provide ice chips if not contraindicatedMonitor I/O to prevent fluid deficit or overloadMonitor serum K+ level for hypokalemia1617Check residual volume before feedingsResidual is the amount of formula found in the stomach while a pt is receiving a tube feeding

ideal residual amount is zero=0171718The residual volume tells you:if GI motility is adequateif pt is tolerating feeding &/or formula if rate or volume of feeding is too great for pt if there is a blockage in GI tract

A high residual volume is dangerous - can cause reflux, vomiting, & aspiration

1818Enteral Feeding MethodsIntermittent tube feedingsBolus feedingsContinuous infusion feedings

1920Feeding Tube SchedulesContinuous feedings are a constant flow of formula & an even distribution of nutrition throughout the day or night

Usually pts who cant tolerate large amts at a time Instilled via a controlled pump infusion, drop by drop similar to an IV set up ie. Isocal 100cc/hrThe amount is ordered by the MD202021Residual Rule for Continuous tube feedings:Check gastric residual volume every 4-6 hrs. If the residual volume is more than formula rate per hour hold the feeding for 1 hour & recheck.Replace residual volumes unless residual volume is high (100cc or facility amt) check with MD to find out if residual should be replaced212122Feeding Tube SchedulesIntermittent feedings are given usually to supplement oral intake or for patients who desire greater mobility (bolus)

Are given on a regular or periodic basis several times a day ie. 240ml Isocal q4hFormula should administered by gravity, but should not be pushed. 222223Residual Rule for Intermittent tube feedingCheck gastric residual volume prior to each feeding.If gastric residual is greater than the volume given in the last intermittent feeding..hold the feeding for 1 hr & recheck in 1 hr.Replace residual volumes unless residual volume is high (150cc or facility) check with MD to find out if residual should be replaced.232324ResidualsResiduals for both continuous & intermittent feedings should be returned to the pt or replaced! (unless very large then the MD should be consulted)

****Hospital policy may vary these #2425Nursing considerations:Bolus Intermittent Tube Feeding Allow 5-10 mins for feeding to flow into stomach & before & after feeding flush with 30 mL water to prevent cloggingContinuous Tube FeedingFeeding may be stopped for med administration or patient care, such as...252526Equipment & FormulasAll equipment is cleanPrefilled (closed system)-disposable & discarded after use. Can safely hang for 24 hrs if sterile technique is usedCans of formula (open system)-are opened & instilled via a syringe or poured into a reusable bag. Feedings should not hang for more than 6 hrsAdminister feedings at room temperatureCheck expiration date of any feeding prior to administration

2626Complications of Enteral Tube FeedingsAspirationElectrolyte imbalanceHyperglycemiaSevere diarrheaInfection at site of insertion2728How will you know if your pt is not tolerating a formula?Abdominal distention, abdominal discomfort

Nausea, vomiting, diarrheaLarge residuals

282829Complications of Enteral Tube Feedings contdClogged tubesCommon causesThick formulas Low rate of delivery (< 50 mL/hr) Instilling crushed meds thru tube Inadequate flushing of tube

292930Prevention of Clogged tubesFlush tube frequently w/water (NS if ordered):Immediately before & after Bolus intermittent feeding

Every 4 hrs for continuous feeding

After residual check

Before & after instilling meds303031Nursing ResponsibilitiesHOB up at least 30 Monitor wtsAssess bowel sounds & BMs (diarrhea/constipation)Monitor I&OPerform oral care at least q 2-4 hrs Monitor skin breakdown & infection (nose for NGT & insertion site for GT/JT)

313132Nursing Responsibilities contdCheck tube placement before each feedingCheck residual volume before each feedingLab values (blood glucose, BUN, & electrolytes)Feeding residualGastrointestinal status

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