Out line Define the nasogastric tube Discuss the types of nasogastric tube .List the purpose of using the nasogastric tube Discuss insertion nasogastric tube Discuss removing nasogastric tubeDiscuss administering a tube feeding Discuss Irrigating Nasogastric TubeExplain the procedure.List the potential complications of Nasogastric Tube.Demonstrate the procedure.

Introduction Gastrointestinal intubation is inserting of rubber or plastic tube into the stomach , duodenum or intestinal The tube inserted through mouth .nose , or abdominal ( gastrostomy .jejunostomy ) The tube short , medium , long

Types of TubesShort- Nasogastric tubeIntroduced from the nose to the stomachLevin and Gastric (Salem) SumpUsed to remove gas and fluid from the upper GI tract or to obtain a specimen of gastric contentsSometimes used for medications or feedings ( gavage )

Levin TubeSingle Lumen (hollow part of tube)Size 14-18 FrenchMade of plastic or rubber with opening near tipIt is 125 cm long Circular markings on the tube serve as insertion guides

Gastric (Salem) SumpGastric sump tube ( salem. Ventrole)Double lumen catheter .clear plastic Plastic, 12-18 FR.It is 120 cm long Used to decompress the stomach, keeps it empty

Smaller, inner tube (blue pigtail) vents the larger suction-drainage tube to the atmosphere by way of an opening at the distal end of the tube.Keeps the suction force at the drainage openings at less that 25 mm Hg to prevent capillary irritation.Connected to low continuous suction.Vent lumen kept above the clients waist.

Medium tubes.Medium length- nasoenteric used for feeding. Example- DobhoffPlaced in the duodenum or jejunum by fluoroscopy (x-ray dept) or at clients bedside. Verified by x-ray before feedings begin. May take up to 24 hrs. to pass through the stomachinto the intestines.Place client on right side to facilitate passage

Long- nasoenteric tubes.Long- nasoenteric tubes introduced through the nose and passed through the esophagus and stomach into the intestinal tract.Used to aspirate intestinal contents-ie. gas and fluidUsed to (Decompression) to prevent intestinal obstruction.Due to peristalsis, prevents vomiting, reduces tension at the incision line and prevents obstruction.

Long- nasoenteric tubes.Examples of long tubes: Miller- Abbott- is double lumen ( 12--- 18 fr ) 300 cm rubber tube one lumen used for aspiration and other for Introduce with mercury, water, or saline

Long- nasoenteric tubesHarris-Is single lumen ( 14 fr ) used for suction and irrigation mercury-weighted of about 180 cm This tube metal tip that lubricate This use for irrigation & suction .

Long- nasoenteric tubesCantor tube has a large balloon at distal end of tube. Filled with 4- 5 ml of mercury, water or saline to weight the tubeIt is 300 cm long

Procedure of Inserting nasogastric tube

DefinitionTube inserted through the nose into stomach

Purposes:

To administer tube feedings and medications to clients unable to eat by mouth or swallow a sufficient diet without aspirating food or fluids into the lungsTo establish a means for suctioning stomach contents to prevent gastric distention ,nausea, and vomiting.To remove stomach contents for laboratory analysisTo lavage(wash)the stomach in case of poisoning or overdose of medications.

PurposesTo drain fluid or air from the stomach. To promote healing after bowel surgery.To monitor bleeding in the gastrointestinal (GI) tract. To help treat an intestinal obstruction.

Assessment & Preparations:Assessment & Prepare the client

Presence of gag reflex Mental status or ability to cooperate with procedure Check physician's order for insertion of NG tube.Explain procedure to patient. Assist the patient to high Fowler's position.Drape chest with disposable pad

Assess the client naresAsk client to hyperextend the head & using flashlight Observe ( intactness of tissue nostrils including any irritation or abrasion ) Examine the patients nostril for septal deviation. To determine which nostril is more patent, ask the patient to occlude each nostril and breathe through the otherPatency of nares & intactness of nasal tissue ( note especially history of nasal surgery or deviated septum )

Assess & prepare the tubeIf rubber tube : used placed it on ice for 5 to 10 minutes This stiffens the tube , facilitating insertion If plastic tube Used place it in warm water until tube softer & more flexibility , facilitating insertion

Equipments:

Nasogastric tube Adult- 16-18F Viscous lidocaine 2% Oral analgesic spray (Benzocaine spray or other)Oral syringe, 12 mL Glass of water with a straw Water-based lubricant

Equipments:

Non allergenic adhesive Tape 2,5 cm wide Emesis basin or plastic bag Wall suction, set to low intermittent suction Suction tubing and container Flashlight .Stethoscope.Toomey syringe (20 to 50 ml) .TissuesDisposable pad & gloves . . Tongue blade . Normal saline solution (for irrigation only).

Procedure:

NoteA nasogastric (NG) tube is used for the procedure. The placement of an NG tube can be uncomfortable for the patient if the patient is not adequately prepared with anesthesia to the nasal passages and specific instructions on how to cooperate with the operator during the procedure

Determine how far to insert the tubeMeasure the distance to insert tube by placing tip of tube at client's nostril and extending to tip of ear lobe and then to tip of xiphoid process. Mark tube with piece of tape.

Nasogastric tube lubrication with water-based lubricant.

Estimation of nasogastric tube length from nostril to stomach

Insert the tubePrepare equipment.Wash hands. Wear disposable gloves.Instill 10 mL of viscous lidocaine 2% (for oral use) down the more patent nostril with the head tilted backwards, and ask the patient to sniff and swallow to anesthetizeLubricate tip of tube with water soluble lubricant.Ask client to lift head, and insert tube into nostril while directing tube upward and backward.

Aspiration of viscous lidocaine into an oral syringe

insert of viscous lidocaine 2%

Cont,,

If client gag when tube reaches pharynx, provide tissues for tearing or watering of eyes.When pharynx is reached, instruct client to touch chin to chest. Encourage client to sip water through a straw or swallow even if no fluids are permitted.

Patient flexing his neck and drinking water while a nasogastric tube is inserted.

Advance tube in downward and backward direction when client swallows. Stop when client breathes.If gagging and coughing persist, check placement of tube with tongue blade and flash light. Keep advancing tube until tape marking is reached.Do not use force, rotate tube if it meets resistance.Discontinue procedure and remove tube if there are signs of distress, such as gasping, coughing, cyanosis, and inability to speak or hum.

Confirming PlacementTube placement is confirmed prior to any use of the tube for suction, irrigation, medication admin. or feedings.Initially, an x-ray should be ordered to confirm placement of weighted feeding tubes (Dobhoff).Verify NG or Salem Sump tubes by auscultation of an injected air bolus over the epigastrium or aspirate stomach contents.Measurement of tube length, visual inspection and measuring of the aspirate pH is also recommended.

Auscultation over the stomach

Nasogastric tube in lung.

Securing the GI tubeUse a skin barrier to prep the skinUse NG strip or place a piece of tape under the tube at the nose and secure to the skin, place another piece of tape over the first piece.Secure tube to clients gown with a safety pin.

Secured nasogastric tube.

DocumentDocument: Tube type and sizeDrainage or aspirate (residuals) amount, color and consistency Irrigation type and amount Suction- type and level (i.e. low intermittent)Feeding- type and amountPatient tolerancePatient/ Family education and response

NG SuctionTube for decompression will be attached to Intermittent Suction- keep suction between 20-80mm Hg.Continuous suction greater than 25mm Hg can cause damage to the gastric mucosa.Do not clamp or plug the vent lumen. A soft hissing sound will be heard from the vent lumen if its patent.Record amt. on I&O.

Conte,,,Remove disposable gloves.Wash hands.Remove all equipment.Keep the client at comfortable position.Assist with or provide oral hygiene at regular intervals.

Complications

The main complications of NG tube insertion :-aspiration and tissue trauma. Placement of the catheter can induce gagging or vomiting, Patient discomfort EpistaxisPulmonary complication Esophageal perforation

Contraindications

Absolute contraindications Severe mid face trauma Recent nasal surgery

Relative contraindications Coagulation abnormality Esophageal varicose or stricture Alkaline ingestion

Procedure of Administering a Tube Feeding.

Tube FeedingsMeet nutritional needs when oral intake not possibleAdvantageous over TPNGI integrity is preservedNormal insulin/glucagon ratios are maintainedAdmin. intermittent, continuousAccessed by nasogastric, nasoenteric, gastrostomy or jejunostomy tube

Assessment Before a nasogastric or orogastric feeding determine type amount frequency of feeding & tolerance of previous feeding Assessment signs of malnutrion or dehydration Assess allergies to any food Presence bowel sound Any tolerance of previous feeding ( delayed gastric empty , abdominal distention . Constipation )

Purposes:

To restore or maintain nutritional status.To administer medications.

Equipments:

Feeding container.Large syringe with plunger or calibrated plastic feeding bag with tubing or Prefilled bottle with a drip chamber tubing & flow regulator clamp Stethoscope. Disposable gloves. Alcohol swab.Toomey syringe 20 to 50 ml with adaptor .Water for irrigation or normal saline. Emesis basin Feeding pump as required

Procedure:

Preparation:

Explain procedure to client. Prepare equipment.Check amount, concentration, type, and frequency of tube feeding on client's chart.Check expiration date of formula

ProcedureUse stethoscope to assess bowel sounds.Wash hands.Wear disposable gloves.Position client with head of bed elevated at least 30 degrees or as near normal position for eating as possible. Fowlers position

Performance:

Check to see that the NG tube is properly located in the stomach. Flush tube with 30 ml of water for irrigation.Disconnect syringe from tubing.Warm feeding to room temperature Assess residual feeding contentAspirate all stomach content & measure a mount prior to administering the feeding

Feeding bag Open system ) )Cleanse top of feeding container with alcohol before opening it. Pour formula into feeding bag and allow solution to run through tubing.Close clamp.Attach feeding setup to feeding tube.Open clamp.Regulate drip according to physician's order, or allow feeding to run in over 30 minutes.

Feeding bag Open system ) )Add 30 to 60 ml of water for irrigation to feeding bag when feeding is almost completed and allow it to run through the tube.Clamp tubing immediately after water has been instilled.Disconnect from feeding tube.Clamp tube and cover end.

Open system ) ) Syringe feedingRemove plunger from 30- or 60-ml syringe.Open clamp.Attach syringe to feeding tube.Pour amount of tube feeding into syringe.Allow food to enter tube. Regulate rate, by height of the syringe.Do not push formula with syringe plunger.When syringe has emptied, hold syringe high.

Syringe feedingAdd 30 to 60 ml of water for irrigation to syringe when feeding is almost completed, and allow it to run through the tube.Clamp tube .Disconnect from tubeCover end of tube.Observe the client's response during and after tube feeding. Keep client in upright position for

at least 30 minutes to 1 hour after feeding. Remove gloves. Wash hands

Documentation:

Record type and amount of feeding, residual amount ,and client's response, monitor blood glucose level, if ordered by physician.

Procedure of Irrigating Nasogastric Tube

Purposes:

To clears the tube of feeding or debris.To prevent the spread of microorganisms in the tube of feeding.

Equipments:

Normal saline solution or water for irrigation. Disposable gloves. Stethoscope. Toomey syringe. Container. Disposable pad.

Procedure:

Preparation:

Check physician's order for irrigation.Explain procedure to client.Prepare necessary equipment.Check expiration dates on irrigating solution.Wash hands. Wear disposable gloves.Assist client to semi-Fowler's position.Check placement of NG tube.Pour irrigating solution into container. Draw up 30 ml of saline solution.Place tip of syringe in tube.

Hold syringe upright and gently insert the irrigate or allow solution to flow in by gravity. Do not force solution into tube.If unable to irrigate tube, reposition patient and attempt irrigation again. Withdraw or aspirate fluid into syringe.If no return, inject 10 to 20 cc of air and aspirate again.Measure and record amount and description of irrigant and returned solution.Remove equipment& gloves.Wash hands.

Documentation:

Record irrigation procedure, description of drainage, and client's response.

Procedure of Removing a Nasogastric Tube

Purposes:

The physician will order the tube to be removed carefully, when the NG tube is no longer necessary for treatment:To provide as much comfort as possible for the client.To prevent complications.

Equipments:Tissues.50-ml syringe (optional). Disposable gloves.Disposable plastic bag.Disposable pad.Normal saline solution or water for irrigation (optional).Emesis basin.

Procedure:

Preparation:Check physician's order for removal of NG tube.Explain procedure to client. Assist to semi- Fowler's position.Prepare equipment.Wash hands.Wear clean disposable gloves.Place disposable pad across client's chest. Give emesis basin and tissues to client.Attach syringe and flush with 10 ml of water or normal saline solution.

Carefully remove adhesive tape from client's nose.Instruct client to take a deep breath and hold it.Clamp tube with fingers by doubling tube on itself.Quickly and carefully remove tube while client holds breath.Dispose of tube. Remove gloves and place in bag.Clean and dry face, nose and mouth.Remove all equipment and dispose of according to agency policy.& Wash hands.

(Total parental nutrition( TPN

Definition of Parenteral NutritionThe administration of complete and balanced nutrition by intravenous infusion in order to support anabolism, body weight maintenance or gain, and nitrogen balance, when oral or enteral nutrition are not feasible or are inadequate

Indications for TPNMall absorption syndromes, such as short bowel syndromeConditions requiring complete bowel rest for prolonged periodsPre and post-operative support in patients with pre-existing malnutrition, in who GI function is impairedMalignancy undergoing treatment, surgery, radiation, chemo who are unable to obtain adequate nutrition by an enteral route

TPN is generally NOT indicatedWhen an inpatient has a functioning GI tractTPN therapy is expected to be less than 5 daysPrognosis does not warrant aggressive nutrition support

Source of NutritionEternal nutritionParenteral nutritionCentral parenteral nutrition (CPN=TPN)Peripheral parenteral nutrition (PPN)Long-term home parenteral nutrition (HPN)

Clinical decision algorithm route of nutrition supportDecision to institute special nutrition support Oral FeedingNutrition AssessmentFunctional GI TractEnteral NutritionParenteral NutritionGI function

PPNTPNGI function return

IntactNutrientsDefinedFormula

AdequateInadequatePNShort-term: NG, ND,NJLong-term:Gastrostomy JejunostomyYESNONOYES

Adequate

Components of TPNCarbohydrate, Amino acid, Fat, Electrolyte, Water, Vitamin, Trace elementStandard solutionDextrose, Amino acidElectrolyte (Na, K, Cl, Mg, Ca, P)Vitamin (A, B1, B2, Niacin, B6, Panthothenic acid, C, D, E, Zn, Cu, Mn, Cr)Lipid emulsion

Total Parenteral Nutrition Normal Diet------------------- TPNProtein--------------------------Amino AcidsCarbohydrates------------------DextroseFat--------------------------------Lipid EmulsionVitamins--------------------Multivitamin InfusionMinerals------------------------Electrolytes and Trace Elements

complicationMechanical: thrombosis, embolism, skin sloughInfectious: particularly staph epidermidis, CandidaMetabolic: hypoglycaemia, hyperglycaemia,

cholestasis