NASOGASTRIC TUBE INSERTION, REMOVING ADMINISTRING INTERNAL FEEDING & CARING OF GASTROSTOMY OR JEJUNOSTOMY /

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NASOGASTRIC TUBE INSERTION (NGT): Indications By inserting a nasogastric tube, you are gaining access to the stomach and its contents. This enables you to drain gastric contents, decompress the stomach, obtain a specimen of the gastric contents, or introduce a passage into the GI tract. This will allow you to treat gastric immobility, and bowel obstruction. It will also allow for drainage and/or lavage in drug over dosage or poisoning. In trauma settings, NG tubes can be used to aid in the prevention of vomiting and aspiration, as well as for assessment of GI bleeding. NG tubes can also be used for internal feeding initially. Contraindications

Nasogastric tubes are contraindicated in the presence of severe facial trauma (cribriform plate disruption), due to the possibility of inserting the tube intracranially. In this instance, an orogastric tube may be inserted. Complications The main complications of NG tube insertion include aspiration and tissue trauma. Placement of the catheter can induce gagging or vomiting, therefore suction should always be ready to use in the case of this happening. Universal precautions: The potential for contact with a patient's blood/body fluids while starting an NG is present and increases with the inexperience of the operator. Gloves must be worn while starting an NG; and if the risk of vomiting is high, the operator should consider face and eye protection as well as a gown. Trauma protocol calls for all team members to wear gloves, face and eye protection and gowns. Equipment: All necessary equipment should be prepared, assembled and available at the bedside prior to starting the NG tube. Basic equipment includes: 1- Personal protective equipment 2- NG/OG tube 3- Catheter tip irrigation 60ml syringe 4- Water-soluble lubricant, preferably 2% Xylocaine jelly 5- Adhesive tape 6- Low powered suction device OR Drainage bag 7- Stethoscope 8- Cup of water (if necessary)/ ice chips 9- Kidney basin 10- pH indicator strips Procedures:

1- measuring the NGT.

2- lubricant the tube and insert it.

3- Check the placement of the tube by aspirate sample of gastric contents.

1. 2. 3. 4. 5. 6.

4- Secure tube with tape.

Gather equipment Don non-sterile gloves Explain the procedure to the patient and show equipment If possible, sit patient upright for optimal neck/stomach alignment Examine nostrils for deformity/obstructions to determine best side for insertion Measure tubing from bridge of nose to earlobe, then to the point halfway between the end of the sternum and the navel 7. Mark measured length with a marker or note the distance 8. Lubricate 2-4 inches of tube with lubricant (preferably 2% Xylocaine). This procedure is very uncomfortable for many patients, so a squirt of Xylocaine jelly in the nostril, and a spray of Xylocaine to the back of the throat will help alleviate the discomfort. 9. Pass tube via either near posterior, past the pharynx into the esophagus and then the stomach. Instruct the patient to swallow (you may offer ice chips/water) and advance the tube as the patient swallows. Swallowing of small sips of water may enhance passage of tube into esophagus. If resistance is met, rotate tube slowly with downward advancement toward closes ear. Do not force. 10. Withdraw tube immediately if changes occur in patient's respiratory status, if tube coils in mouth, if the patient begins to cough or turns pretty colors 11. Advance tube until mark is reached

12. Check for placement by attaching syringe to free end of the tube, aspirate sample of gastric contents. Do not inject an air bolus, as the best practice is to test the pH of the aspirated contents to ensure that the contents are acidic. The pH should be below 6. Obtain an x-ray to verify placement before instilling any feedings/medications or if you have concerns about the placement of the tube. 13. Secure tube with tape or commercially prepared tube holder 14. If for suction, remove syringe from free end of tube; connect to suction; set machine on type of suction and pressure as prescribed. 15. Document the reason for the tube insertion, type & size of tube, the nature and amount of aspirate, the type of suction and pressure setting if for suction, the nature and amount of drainage, and the effectiveness of the intervention.

Responsibility The person responsible for administering the feed will have received the appropriate training and demonstrated competency. Definition Enteral feeding refers to tube feeding via the gut Naso-gastric, Naso-jejunal, Gastrostomy, Gastro Jejunostomy, Jejunostomy. Feed regimens, administration rates and delivery methods i.e. pump/gravity/bolus may vary, although renewal of the consumables for feed delivery and drug administration is not open to interpretation. Aim To provide nutrition via the enteral route, in a safe environment to minimise risk to the patient. Main source of contamination:-

Poor hand hygiene. Feed interruption handling without observing hand hygiene. Feeding set in situ for over 24 hours. Decanting.

Standards/Competencies
1. The person directly responsible for administering the feed has received formal training and is competent. 2. Ensure that all equipment is clean this includes pumps and drip stands. 3. Wash hands thoroughly apply non sterile gloves when manipulating open ends which includes changing feed bottle/bag. 4. Do not decant feed unless advised to do so by Dietitian/Nutrition Nurses/Children Community Nurse. 5. In exceptional circumstances when decanting is required use bottles of feed/made up feed and pour into an integral reservoir. If Back Pack required use water container for feed. Label the reservoir or container with name of feed and change 12 hourly. 6. Decanting rationale for paediatric feeds. 7. Do not dilute feed unless specifically authorized by the General Practitioner /Consultant/ Dietitian/Nutrition Nurse. 8. Feed administration sets must not be reprocessed or used beyond 24 hours. 9. Clearly label administration set with date/time. 10. Cover the distal end of the feed admin. set when not in use with end supplied with administering set. 11. A separate water container must be used to administer water. These are available and are compatible with the feed administration set, therefore one set can be used for feed/water in 24 hour period. When not in use the neck of the water bottle needs to be covered (blue cap supplied with water container). If an integral reservoir is in use for a special feed a separate water container is not required, simply decant into the integral reservoir. 12. Water containers should be changed every 24 hours clearly label with date/time. When not in use the blue cap should be stored in a large eternal box and discarded after 24 hours. 13. Single use syringes discard after use or as recommended by Nutrition Nurse/Community Nurse. 14. Single patient use syringes (i.e. Baxa) are available, which can be reprocessed and used in place of single use syringes. 15. The large internal box will be used to store all single patient use items which can be reprocessed i.e. syringes, connectors, adapters and extension sets. All these items should be discarded after one week. 16. Reprocessing should be carried out as defined. 17. Patients receiving feed must be referred to Clinical Nutrition Nurses/Dietitians/Community Paed Nurses. 1. 2. 3. 4.

The wearing of non sterile gloves is optional for patient and family members. Labeling is optional for patient and family members. Integral reservoirs must be changed 12 hourly unless a 24hr hanging time can be justified. Water container required as Back Pack will not accommodate an integral reservoir.

Guideline for feed delivery via a pump Requirements: Dripstand Enteral pump Administration Set Syringe Water Non Sterile Gloves (optional for patient and family) Feeding Pack Water Pack (Container) Instructions for priming the pump Aim of Care
1. To administer the feed as prescribed with minimal discomfort to the patient. 2. To reduce the risk of infection by adhering to the enteral feed administration working document. 3. To provide individual choice, based on physiological, psychological and social need. Principles of Safe Practice 1. The feeding regimen is tailored to meet the physiological requirements of each patient.

Further considerations:- * The location of the enteral access * The patients clinical status. * How long Nil by Mouth * Patient position * The starter feed - always give Isotonic feed initially (Nutrison Standard) unless specifically instructed to do otherwise * Guide only (adult) - start feed at 30/50 ml per hr as tolerated unless contraindicated. Procedure - Feed ACTION RATIONALE 1. Explain procedure to patient. Gain consent where appropriate. To reduce anxiety and enable therapy acceptance. Promoting dignity and self-respect.

2. Select an appropriate area where feed can be given safely. Protect at all times the individuals right to privacy and dignity. 3. Wash hands prior to handling feed and feeding system.

Prevention of infection. Follow Infection Control guidelines. Cold feeds can cause

4. Prepare and check equipment. Prepacked feed should be stored at

room temperature. Label feed pack/water container.(1)

gastric spasm. Follow enteral standards document.

5. Apply gloves(2) Close roller clamp on administration set. 6. Feed:- Screw administration set into feed pack. Water:- pre fill water container with tap water or cooled boiled water, screw administration set into water container.

Prevention of infection universal precautions for coming into contact with body fluids. The exception to tap water are young children or the immunocompromised patient, when cooled boiled water or sterile water should be used.

7. Prime pump as per instructions. Cover distal end of administration set. (refer to Standards) 8. If NGT insitu check enteral feeding tube position if required. 9. Using syringe flush tube with water (usually tap water). The amount of water will be dependent on individual patient requirements i.e. flush vs hydration.

To reduce contamination.

Follow instructions for passing NGT to ensure safe feed delivery. To ensure potency and hydrate. The exception to tap water are young children or the immunocompromised patient, when cooled boiled water or sterile water should be used. Risk of aspiration if patient fed in flat position. Follow enteral administration standards.

10. Position patient in semi-upright position prior to commencement of feed unless this is contraindicated. 11. Attach administration set to tube and start pump. Place distal cover in enteral box.

12. Support administration set. To prevent enteral tube displacement or discomfort. 13. At end of feed disconnect administration set from tube. Flush tube with water as in 9 above and cover distal end of set. Discard administration set after 24 hours. To avoid blockage of tube and reduce contamination.

REMOVING A NASOGASTRIC TUBE:AIM To remove a nasogastric tube so as to cause minimal discomfort to the patient. EQUIPMENT
1. Incontinence pad 2. Tape remover

3. 4. 5. 6.

Gloves Waste receptacle Syringe 10mL Tissues

PROCEDURE ADDITIONAL INFORMATION 1- Explain the procedure to the patient. Relieves anxiety and aids cooperation. 2- Place emesis bowl within reach. 3- Flush the tube with air. Clears any residual fluid from distal tube. 4- Gently remove tape. Use a tape remover to reduce skin trauma. 5- Occlude the tube using finger and thumb. 6- Ask the woman to take a deep breath. 7- Withdraw the tube gently but quickly. 8- Ask patient to wipe her nose. 9- Leave patient comfortable. 10- Discard equipment. 11- Document removal & update FBC. Minimizes the risk of fluid aspiration during withdrawal.

Caring for gastrostomy or jejunostomy:-

Caring of gastrostomy-jejunostomy tube

A gastrostomy-jejunostomy tube - commonly abbreviated as "G-J tube" - is a tube that is placed into patients stomach and small intestine. This tube is used to vent patients stomach for air or drainage, and / or to give patients an alternate way for feeding. You will use the J-tube to feed patient. The word "gastrostomy" comes from two Latin root words for "stomach" (gastr) and "new opening" (stomy). "Jejunostomy" is made up of the words for "jejunum" (or the second part of the small intestine) and "new opening." The tube stays in your patients stomach because there is a balloon or a plastic bumper at the end of the tube inside the stomach. There is a plastic disc around the tube outside of the child's body. This keeps the tube from sliding in and out of the opening. This plastic disc should not slide around on the tube. The tube should be able to move in and out of the child's stomach just slightly. The plastic disc should be snug against the skin, (the space between the bottom of the disc and the stomach should be about the depth of a dime) but it should not cause pressure. There is a small tube (the J-tube) that will go into the jejunum. There is a balloon that will sit inside the stomach that will hold the tube in place. On the end of each tube are three ports: gastric, jejunal and balloon. These are all clearly labeled and your doctor or nurse will give you further instructions for their use. Supplies Soap and water Hydrogen peroxide (H2O2) Clean gauze pads Catheter tip syringe (35 ml) Water for flushing the tube Procedure
1. Cleaning and dressing the wound 2. Wash your hands with soap and water. 3. Remove the old dressing. Look at the area where the tube enters the skin. Check for redness, swelling, green or yellow liquid drainage, or excess skin growing around the tube. A small amount of clear or tan liquid drainage is normal. See the problem solving list in the last section for what to do if you notice any of these things. 4. Clean the skin under the plastic piece around the tube with soap and water or during bath time / shower. Then rinse the skin using clean tap water and dry thoroughly. 5. To clean crusted drainage off of the skin, tube or disc, use half-strength hydrogen peroxide (1 tablespoon hydrogen peroxide mixed with 1 tablespoon water) and cotton swabs. Dry with a clean cotton swab. 6. If there is any drainage at the disc, place one 2 x 2 softwick piece under the plastic disc. 7. Do not rotate a jejunal tube. This can cause kinking. Flushing the G-J tube To flush the G-J port of your tube, slowly push warm clean tap water into the side opening of the G-port or J-port of the connector. The syringe may be washed in warm water, air dried and reused. Giving medication or feeding

Your doctor or nurse will give you instructions on what port medications and feedings should be given. Be sure to follow their instructions carefully. Do not mix medications unless you are instructed to by your doctor. Protecting the tube
1. Keep your child from pulling on his / her tube. There are several different ways of securing a G-J tub. Your child's doctor or nurse will discuss these with you. Here are some suggestions: 2. Keep the tube taped or pinned to the diaper or shirt. 3. Keep the child's T-shirt over the tube. One-piece, snap T-shirts work best for infants and toddlers. 4. An alternate way to cover the tube is to use an ACE wrap or stretchy gauze over it. 5. Most children get used to the tube after a while, but until they do, they may need to wear elbow splints if necessary. 6. Be sure to keep the end of the tube closed as directed. Problem solving The following are emergency problems that can occur with a G-J tube. For an emergency, take your child to the emergency room. Emergency Problem What to do before coming to the Emergency Room

G-J tube is forcefully pulled out.

If bleeding occurs, press on the site with a clean soft cloth. The opening in the stomach may close within hours, so it is important not to wait before coming to the Emergency Room. When a G-J tube is replaced is is important to verify that the tube is in the right place, by taking an x-ray. Be sure to bring the tube with you to the Emergency Department.

The following are non-emergency problems that can occur with your child's G-J tube. Remember to notify your child's doctor if your child will miss a feeding because of a problem with his / her G-J tube. Problem Corrective Action 1. Leakage tube position. 1. Check tube position. Be sure that retention device is holding tube snugly against the abdomen. Check balloon volume and fill to correct volume. Apply skin barrier to protect skin from corrosive drainage. Consider inserting smaller tube to allow tract to contract and close inward. 2. Adjust retention disc to prevent excessive pressure on the skin. Correct cause of leakage. Apply skin wafers for protection and healing.

2. Skin erosion

3. Tube migration

3. Deflate balloon. Pull tube back into stomach. Reinflate balloon and pull tube snugly up against abdominal wall. Apply retention device. Check for placement per institution policy prior to resuming feedings. 4. Keep tube and tube site clean and dry. Avoid use of dressings. topical antifungal powder (per MD order for yeast rashes). Report S/S's promptly to MD.

4. Local infection