Unit 4

basic human needs, e. feeding

Overview

Intubating the client with an NG tube Types of Tubes Indications for their use Steps to insert NG tubes Enteral Feedings NG tube feeding Indications and Complications. Gastrostomy Parental feeding
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Types of Tubes
Short tubes: passed through the nose into the
stomach
Levin tube: range in size from 14 to 18 Fr,

single lumen made of plastic or rubber with holes near the tip. Gastric Sump (Salem): is radiopaque, clear plastic double lumen

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Types Cont.
Medium Tubes: tubes are passed through the
nose to the duodenum and the jejunum. Used for feeding
Polyurethane or silicone rubber feeding tubes

have a narrower diameter (6 to 12fr) and require the use of a stylet for insertion

Long tubes: passed through the nose,

through the esophagus and stomach into the intestines. Used for decompression of the intestines.
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Indications for GI Intubation

To decompress the stomach and remove gas and

fluid To lavage the stomach and remove ingested toxins To diagnose disorders of GI motility and other disorders To administer medications and feedings To aspirate gastric contents for analysis

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Intubating the client with an NG tube

Assessment:
Who needs an NG: Surgical clients Ventilated client Neuromuscular impairment . Clients who are unable to maintain adequate oral intake to meet metabolic demands. Assess patency of nares.

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Assessment cont.
Assess clients medical history: Nosebleeds Nasal surgery Deviated septum Anticoagulation therapy Assess clients gag reflex. Assess clients mental status. Assess bowel sounds.

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Articles

Non sterile gloves . Feeding cup with water . Water-soluble lubricant. Mackintosh and Towel. Kidney tray Flashlight or penlight Hypoallergenic tape, Number 6, 8, 12 French tube for gastric suction (Levine, Salem sump, or Anderson) or a small-bore feeding tube 20-ml syringe or asepto syringe, 30 ml or larger with small bore tube feeding
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Paper bag Suction apparatus A bowl with water clamp

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 1. Review clients medical record.

Nasogastric Tube Insertion 2. Gather equipment. Wash hands. 3. Check clients armband; explain procedure, showing items. 4. Place client in Fowlers position, at least a 45 angle or higher, with a pillow behind clients shoulders; provide for privacy. Place comatose clients in semi-Fowlers position. 5. Place towel over chest, put tissues in reach. Don gloves.
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 6. Examine nostrils and assess as client

breathes through each nostril. 7. Measure length of tubing needed by using tube as a tape measure: Measure from bridge of clients nose to earlobe to xiphoid process of sternum If tube is to go below stomach (nasoduodenal or nasojejunal), add an additional 15 to 20 cm. Place a small piece of tape on tube to mark length.
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 8. Have client blow nose and encourage

swallowing of water if level of consciousness and treatment plan permit. 9. Lubricate first 4 inches of tube with watersoluble lubricant. 10. Insert tube as follows: Gently pass tube into nostril to back of throat (client may gag); aim tube toward back of throat and down. When client feels tube in back of throat, use flashlight or penlight to locate tip of tube. Instruct client to flex head toward chest.
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Instruct client to swallow, offer ice chips or water, and advance tube as client swallows. If resistance is met, rotate tube slowly with downward advancement toward clients closest ear; do not force tube. 11. Withdraw tube immediately if changes occur in respiratory status. 12. Advance tube, giving client sips of water, until taped mark is reached. 13. Check placement of tube: Attach syringe to free end of tube and aspirate sample of gastric contents. If prescribed, obtain x-ray; keep client on Slide 16 right side until x-ray is taken.
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Split a 4-inch piece of tape to a length of 2 inches and secure tube with tape by placing the intact end of the tape over the bridge of the nose. Wrap split ends around the tube as it exits the nose. Place a rubber band, using a slip knot, around the exposed tube (1218 inches from nose toward chest); after x-ray, pin rubber band to clients gown.

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15. Instruct client about movements that can dislodge the tube. 16.aspirate the gastric content with the syringe and Observe nature and amount of gastric tube drainage. Assess client for nausea, vomiting, and abdominal distention. 17. Provide oral hygiene and cleanse nares with a tissue. 18. Remove gloves, dispose of contaminated materials in proper container, and wash hands.

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Nasogastric Tube Position

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19. Position client for comfort, and place call light in easy reach. 20. Document: The reason for the tube insertion The type of tube inserted The type (intermittent or continuous) of suctioning and pressure setting The nature and amount of aspirate and drainage The clients tolerance of the procedure The effectiveness of the intervention, such as nausea relieved
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Enteral Nutrition
What is it:
The administration of nutrients directly into the

GI tract. The most desirable and appropriate method of providing nutrition is the oral route, but this is not always possible. Nasogastric feeding is the most common route Nurses are the main healthcare professional responsible for intubation Second important feeding is gastrostomy feeding and orogastric feeding
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Alternate Routes for Enteral Tube Feeding

Esophagostomy Percutaneous endoscopic gastrostomy (PEG) Percutaneous endoscopic jejunostomy (PEJ)

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Tube Feeding

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Administering Enteral Feeds

Indications:
Clients who are unable to maintain adequate

oral intake to met metabolic demands Surgical cases Ventilated clients Neuromuscular impairment Clients requiring bowel rest.

Generally these clients have been referred to

the Dietician.

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Administering Enteral Feeds

Contraindications:
Clients with diffuse peritonitis. Severe pancreatitis Intestinal obstruction Severe D&V Paralytic ileus.

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Nursing Care or procedure

Confirm satisfactory tube positioning before starting
tube feed and aspirate the gastric content. Right product, right time, right client, right rate..check and chart. Monitor intake and output

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Nursing Care Cont.

Flush tube with a min of 30-50cc water prior to
initiating feed, when feed is finished, before and after the administration of medications.
For immune compromised clients use sterile water For non-immune compromised use tap water

(refer to policies of the institution

Change feed bag and tubing q24h, need to label and

chart Elevate the HOB to 30 degrees to prevent aspiration. Note blood values BUN, creatinine, electrolytes and glucose.

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Nursing Care Cont.

Monitor blood glucose q6h until maximum
infusion rate has been increased and maintained for 24h Keep tube feeding formulas at room temperature. A Registered Dietician determines the caloric requirements for each client and orders the formula to be use, the rate and the appropriate amount of water to be used to flush the tube.

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Complications
Clogged Tube- most common
Flush tube with 30-60 cc q4h if continues feed.

Use liquid meds when possible. Flush tube after giving medication. Dumping Syndrome: solution with high osmolalitywater moves into stomach and intestines from the fluid surrounding the organs and vascular system causing dehydration, hypotension and tachycardia Aspiration : ensure head of bed is elevated at least 30 degrees while feeds are being administered

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Complications Cont.
Dehydration- diarrhea is a common problem. Electrolyte imbalance: hyperkalemia and
hypernatremia Oral mucosal breakdown Nasal irritation

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Gastrostomy
Surgical procedure in which an opening is
created into the stomach

Preferred route for prolonged

nutrition((greater than 3 to 4 weeks) Preferred in clients who are comatose decreases the risk for regurgitation and aspiration

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Methods of Insertion
Percutaneous endoscopic gastrostomy (PEG)
may be clamped between feedings Low-profile gastrostomy device (LPGD) may be inserted 3-6 months after initial gastronomy tube placement

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Nursing Care
Monitor site post-op: watch for signs of
infection Assess clients response to change in body image A dressing may be applied over the tube at insertion site. Protects the skin from seepage of gastric acid and spillage of feeds. Provide skin care: Inspect the skin at exit site daily Monitor for accidental removal of tube

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Feeds can be given by gravity

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Client Education
Clients can go home and administer their own
feeds, (or caregiver ) Educational needs:
Teach how to administer a bolus feed How to assess residual volumes before feeds How to maintain patency of tube with flushing

of tube pre and post feeds and medications Elevating head of bed while feeds are administered and 1 hour following Monitor tube length

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Parenteral Feeding Routes

Peripheral parenteral nutrition (PPN): uses
less concentrated solutions through small peripheral veins when feeding is necessary for a brief period (10 days) Total parenteral nutrition (TPN): used when energy and nutrient requirement is large or to supply full nutritional support for long periods of time through large central vein

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Peripheral Parenteral Nutrition

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Catheter Placement for TPN

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Example of Basic TPN Formula Components

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Administration of TPN Formula

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References
Perry & Potter(2002). Clinical Skills &
Techniques(5th ed.). United States: Mosby Smeltzer,S.C., Bare,B.G. (2004). Brunner & Suddarths textbook of medical surgical nursing. Philadelphia: Lippincott. Best, C. (2005). Caring for the patient with a nasogastric tube. Nursing Standard. 20,3,5965. Retrieved September 5 2006, from ProQuest database.

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