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Module 6

•Nutritional management

•Nutrient via tube feeding

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GI Therapy The GIT digests ingested foods and transports nutrients

across its mucosa into the bloodstream. Physical and mechanical processes of digestion begin in the

mouth, …………. The average meal remains for 3 hrs in the stomach, Enzymes & Hormones The role GIT is to dilute, digest, transport, and absorb

nutrients and secretions.

Essential body nutrients

CHO, Fats, Protein, Vit, minerals, water.

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Factors affecting nutrition:

Food habits are a product of many evolving variables such as:

1)Physical factors:

geographic location, food technology, income.

2)Physiologic factors:

health, hunger, stage of development.

3)Psychosocial:

culture, religion, tradition, education, politics, social

status, food ideology,

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Gastrointestinal Tube therapy

Rationale: To provide a means for GI decompression for obstructive

disease or surgical wound healing. To provide a means for temporary postoperative

decompression until normal GI motility is restored. To obtain gastric content samples for analysis (PH, etc). To lavage the stomach to remove blood or toxic ingested

substances. To monitor the quantity of GT bleeding.

Assessment: Verify that Dr. has written orders for type & purpose of

tube to be inserted. Verify that order specifies suction or gravity drainage for

decompression

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Assessment cont’d: Monitor client’s VS , intake and output (I&O), and

relevant lab data e.g. electrolytes.

Monitor ongoing IV fluid replacement therapy.

Utilize a variety of validation technique to determine that tube is patent and in desired position.

Monitor quantity and character of aspirated secretion.

Assess that tube remains patent by regular flashing.

Assess client’s abdomen( e.g. not distended, soft, bowel sounds,…etc) and subjective complaints.

Monitor client’s elimination pattern and character of stool.

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Large – bore NGT insertion:Equipment NGT e.g. Levin, Salem) Irrigation syringe(50ml) with catheter tip Water- soluble lubricant Towel Tissue Emesis basin Stethoscope Glass of water Clean gloves Penlight or flashlight Tape

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Large – bore NGT insertion:Procedure: Elevate head of bed to 45 degree angle.

To promote safety during tube insertion.

Place towel over client’s chest and emesis basin within reach.

Inspect client’s nose to select naris that has better airflow; ask client about deviated septum and previous injury or surgery, and check ability to breathe through both nares by occluding one at a time.

To determine length of tube to be inserted, use tube to measure from the tip of client’s nose to earlobe

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Large – bore NGT insertion:Procedure cont’d: To this measurement, add length from earlobe

to xiphoid process of sternum plus 6 in. mark determined distance on tube with tape or pen.

Coil end of tube over your fingers. (Soften tube and facilitates insertion).

Lubricant the first 3-4 in of tube with Water- soluble lubricant .

With client’s head upright or slightly extended, carefully inserted tube into client’s nostril, aim it toward client’s ear and downward , and gently advance it toward client’s nasopharynx. Rationale: turning and directing tube help it confirm to anatomic passageway . When tube reach nasopharynx, resistance will be felt.

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Large – bore NGT insertion:Procedure cont’d: Have client open mouth and check with penlight

to visualize tube. RATIONALE: To verify that tube is at back of throat and not coiled up in mouth .

Once tube is advanced toward back of the throat, have client flex head forward, then rotate tube 180 degree inward toward client’s other nostril. This helps direct tube past nasopharynx.

Ask client to dry swallow or sip water several times while advancing tube until tape mark is reached. If client gags, briefly stop tube advancement. (swallowing opens upper esophageal sphincter and allows tube enter esophagus.

Aspirate 20-30ml of air into syringe; attach syringe to free end of NGT to check for tube position. Tube must be in elementary canal not in respiratory tract.

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Large – bore NGT insertion:Procedure cont’d: Place stethoscope over client’s

epigastric region, then inject air and listen for swooshing sound. this indicates that tube probably reach stomach.

Keeping syringe attached, pull back on plunger to aspirate gastric contents; check for color and PH of the contents.

Use pen to mark tube near client’s naris for future monitoring of tube placement and possible migration.

Make “pair of pants” of tape by using 2-3 in piece of tape and splitting it half- way up the middle.

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Large – bore NGT insertion:Procedure cont’d: Place body part of pants tape on client's

nose. Wrap tape legs around NGT, to stabilize

tube. Loop piece of tape or rubber band

around tube to pin it to client’s gown. Pin tube or rubber band to client’s gown

to secure tube above client’s stomach. Plug end of tube, or connect end of tube

intermittent\ continuous suction device for decompression.

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NGT IrrigationEquipment: Towel Stethoscope 50 ml irrigation syringe Sterile Normal saline( NS) Clean gloves

Procedure: Place towel underneath tube to protect bed linens.

Disconnect tube from suction. Determine tube placement by auscultation and aspiration of secretions .

Draw up 20-30 ml of normal saline solution. Gently instill NS into NGT or remove syringe

plunger, pour NS solution into barrel, and allow solution to flow in by gravity.

Reconnect tube suction, or reclamp tube if suction is not used. Record in the I&O chart.

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Small – bore NGT feeding:Rationale: To provide a means for intermittent nutritional feeding into

the stomach. To provide a means for continuous nutritional feeding into

the small intestine. To provide a means for medication administration.

Assessment: Verify that Dr. has written an order for type of NGT to be

inserted. Verify that order specifies desired placement on tube ( e.g.

gastric, intestinal). Verify that Dr’s order specifies type, amount, and

frequency of enteral feeding. Validate client’s identity; check room number and

identaband and have client state name. Ausculate to ensure client has bowel sounds.

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Small – bore NGT feeding:Assessment cont’d: Assess that client’s nasal passage is patent to allow tube insertion. Determine if client is able to swallow to assist in tube advancement. Verify that tube is placed in desired location by using several validation

techniques.

Equipment: NGT Water- soluble lubricant Towel Tissue Emesis basin Stethoscope Glass of water with straw clean gloves Penlight or flashlight Tape NS solution Syringe 60 ml pen

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Small – bore NGT feeding:Procedure:

To determine length of tube to be inserted, use tube to measure from the tip of client’s nose to earlobe, then to xiphoid process, then adding 10 in. Small bowel placement requires at least 40 in of tubing . This additional measurement allows tube to migrate into small intestine .

Lubricant the first 3-4 in of tube with Water- soluble lubricant.

With client’s head upright or slightly extended, carefully inserted tube into client’s nostril, aim it toward client’s ear and downward , and gently advance it toward client’s nasopharynx. Rationale: turning and directing tube help it confirm to anatomic passageway . When tube reach nasopharynx, resistance will be felt.

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Small – bore NGT feeding:

Procedure cont’d:

Have client open mouth and check with penlight to visualize

tube. RATIONALE: To verify that tube is at back of throat and

not coiled up in mouth .

Once tube is advanced toward back of the throat, have client

flex head forward, then rotate tube 180 degree inward

toward client’s other nostril. This helps direct tube past

nasopharynx.

Ask client to dry swallow or sip water several times while

advancing tube until tape mark is reached. If client gags,

briefly stop tube advancement. (swallowing opens upper

esophageal sphincter and allows tube enter esophagus.

Aspirate 20-30ml of air into syringe; attach syringe to free

end of NGT to check for tube position. Tube must be in

elementary canal not in respiratory tract.

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Small – bore NGT feeding:

Procedure cont’d:

Place body part of pants tape on client's nose.

Wrap tape legs around NGT, to stabilize tube.

Loop piece of tape or rubber band around tube to

pin it to client’s gown.

Pin tube or rubber band to client’s gown to

secure tube above client’s stomach.

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Intermittent Large– bore NGT feeding:

Equipment:

Prescribed nutritional formula

Calibrated container for measuring formula

Irrigation syringe 50 ml

Calibrated container of water for flushing .

Clean gloves

Preparation: Date and refrigerate open formula can.

Warm refrigerate formula to room temp. (in hot water)

Elevate head of bed to a 30 degree angle or higher.

Assess that NG or gastrostomy tube has not migrated

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Intermittent Large– bore NGT feeding:

Procedure :

Ausculate to ensure client has bowel sounds.

Determine position of NGT using sounds with stethoscope, aspiration of gastric contents.

Aspirate gastric contents to determine residual volume. ( more than one-half of previously delivered, hold feeding and recheck in 1hr

Return aspirated contents to stomach. Because its contain electrolytes; their return helps prevent electrolytes imbalance.

Remove plunger from syringe and attach empty syringe barrel to NGT.

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Intermittent Large– bore NGT feeding:

Procedure cont’d :

Holding syringe no longer than 18 in above client’s

stomach, administer 30 ml water to flush and test

tubing; clamp tubing by folding before syringe

empties.

Pour feeding product into syringe barrel and allow to

flow slowly by gravity over 15 min, forced delivery

increase risk of cramping, nausea, or vomiting.

Clamp tubing before syringe empties or continuously

fill syringe before it completely empties.

Flush tubing with 30 ml water and clamp.