The insertion of

a rubber or plastic tube into the stomach, the duodenum, or the intestine.

mouth, nose, abdominal wall short (NGT) medium (nasoduodenal tube) long (nasoenteric tube)

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 treat an obstruction to compress a bleeding site to aspirate gastric contents for analysis

 Sengstaken-Blakemore tube

bleeding esophageal varices

OGT removal of particles of ingested

substances

 The nasogastric feeding route is not suitable

for all patients, including those with: High risk of aspiration Gastric stasis Gastro-oesophageal reflux Upper gastrointestinal stricture Nasal injuries Base of skull fractures

1) Providing instructions

 upright position Cetacaine (tetracaine/benzocaine) xiphoidspread bib-fashion over the chest Polyurethane tube+ warmed to make placement towel process 6inches for NG it more Liquid wipes for intestinal placement. the anesthetic / hold ice chips in or 8-10 inches inspect nostrils pliable tissue mouth adequate light fowlers position KY jelly (water soluble) privacy with Lubricate and or breaththe nostril and tube is aligned to enter thepant tilt tip of through the mouth Hydromer - when moistened , provides its own nostri often lubrication Nasopharynxwater Swallow : head slightly lowered and begin to swallow wear gloves
as the tube is advaced Check oropharynx to ensure that tube has not coiled in the pharynx or mouth

Measure the distance from the tip of the nose to the earlobe, and from the earlobe to the

High Risks Patients: Visual Assessment of the

Xray 1) Dec. LOC COLOR Injecting air and 2) Confused mental state pH Measurement 1) gastric cloudy and Auscultation green, tan or gag white Gastric acidic tube 3) Poor or absent off- reflex Measurement of (1-5) 1) or bloody 4) Agitation or brown 2) Intestinal 6 or length 2) Intestinal clear and Visual assessment of greater 5) ETT yellow to bile-colored3) Respiratory 7 or aspirate 3) Pleural fluid pale greater pH measurement of yellow or off-white aspirate mucus

 Pyloric sphincter - 5-6cm (2-3inch) q hr

R side for 2hrs, back for 2hrs, L side 2hrs

Ambulation Irrigate c NSS q 6-8hrs to prevent blockade

Too rapid: curing and kinking of tube

 Decompression attached to intermittent low suction

Enteral nutrition end of the tube is plugged between

feedings Confirm tube placement before any meds and fluids are instilled MIO Irrigate tube q 4-6 hrs c NSS Assess amount, color, and type of drainage q 8hrs Double/triple lumen tubes : amount, color, type of drainage

 moistened cotton-tipped swabs

Water soluble lubricant

Mouth care nasal tape 2-3 days

Inspect nose for irritation

Throat lozenges, ice collar, chewing gum, sucking on

hard candies Frequent movement

 FVD
Dry skin and mucous membrane
Dec. urine output Lethargy

Dec. BT

MIO BUN, creatinine

 Pulmonary Complications
impaired coughing and clearing of the pharynx

meds (antacids, siethicone, metoclopramide) s/s: coughing during administration of foods and meds difficulty clearing the airway Tachypnea Fever

 Irritation of Mucous Membrane Nostrils, oral mucosa, esophagus, trachea

irritation Dryness Enlarged nodes around parotid glands Sorethroat hoarseness

 Intermittently lamp and unclamp the NG tube for

24hrs Nausea and vomiting, distention Flush c 10ml of NSS Deflate balloon Wear gloves w/draw tube gently and slowly for 15-20 cm (68inch) Nasoenteral tube: interval of 10 minutes Force should not be used /report to POD Tube removed should be concealed w/ towel Mouth care

 Advantages
Low in cost
Safe Well tolerated by the patient Easy to use

Preserve
GI integrity Maintain fat metabolism and lipoproteins synthesis Maintain normal insulin/glucagon ratios

 NGT, gastrostomy stomach

nasojejunal , nasodoudenal distal doudenum,

proximal jejunum
Bypass esophagus, stomach Risk for aspiration

Long term feedings 1. Nasodoudenal 2. Gastrostomy 3. Jejunostomy

Fluid balance is maintained by

High osmolality solution

Small particles that have great osmotic effects: Osmosis shifts to the stomach and intestines fluid process by which water moves

through acids membranes from a dilute solution of amino lower osmolality to anausea, diarrhea CHOFeeling of fullness, more concentrated solution of (Na, K) Electrolytes higher osmolality until both solutionsDHN, hypotension, tachycardia are of nearly equal osmolality,
DUMPING SYNDROME

Characteristics :

Status of the GI tract

Nutritional needs 1. Chemical composition of the nutrient source 2. Caloric density 3. Osmolality 4. Residue 5. Bacteriologic safety 6. Vitamins 7. minerals 8. Cost

Silastic nasoenteric tube Intermittent bolus feedings (gastrostomy tube) stomach Continuous small intestine (pump) Dec. abdl distention, gastric residuals, risk for aspiration cyclic feeding faster rate over a shorter time

 Temp

Schedule of tube feedings: correct Flow rate quantity, frequency Total fluid intake avoid administering fluids too rapidly

Volume of the feeding

1. Gravity (drip)
placed above the level of the stomach, with the

speed of administration determined by gravity.

2. Bolus feedings
given in large volumes (300-400ml q 4-6hrs)

3. Continuous feedings preferred method =) delivery of the feeding in small amounts over long periods reduces the incidence ______, _______, ____, _____ 100-150mL/hr (2400-300 cal/day)
Nitrogen positive balance, wt gain w/o

abdl cramps and diarrhea

4. Intermittent feeding
200-350ml is given in 10-15mins
Enteral pumps control the delivery rate and can

infuse a viscous formula through a small-diameter feeding tube Measure residual content before each intermittent feeding and q 4-8hrs for cont. feeding
Readminister

 Tube feeding intolerance

volumes occur TWICE, cont. tube feeding the nurse notifies the radigraph studies physician!!!
physical status

Aspirated gastric content : 200ml or greater for NGT If excessive residual 100ml or greater for gastrostomy tubes

Goal:

to ensure patency and to decrease the chance of bacterial growth, crusting, or occlusion of the tube, 2030ml of water is administered in each of the following instances:

1) before and after each dose of 3) Q 4-6hrs c cont. feedings medication and each tube feeding 4) If the tube feeding is DC for any 2) after checking for gastric residuals reason and gastric pH

 each meds is given separately using bolus method

Tube is flushed c 20-30ml of water after each dose

Crushed tabs and dissolve c water Do not mix meds with each other or with feeding

formula small bore feeding tubes for cont feeding infusion are irrigated after meds administration, 30ml or larger syringe is used.

 Diarrhea formulas have little or no residue

Dumping syndrome 2. Dumping syndrome results from rapid Zinc dif. -15mg of zinc q 24hrs (50-150fg/dL) 3. distention of jejunum with hyperonic Contaminated formula 4. solution are administered quickly over Malnutrition 10-20ml/min 5. Medication (clindamycin, lincomycin, quinidine, propranolol, aminophylline , theophylline, digitalis
1.

 established tube placement correctly before

feeding , each med is administered, once q shift Semi feeding immediately stop fowlers position and maintained in Suction pharynx and trachea 1hr after intermittent feeding and all the Placefor cont feedingright side with the time patient on the head of bed down Monitor residual volumes Notify physician

Aspiration:

 Water at least 2L/day q 4-6hrs and after feeding

At the beginning of the administration, the feeding is

diluted to at least haf-strength and not more than 50100ml is given at a tie, or 40-60mL/hr I given in a cont feeding Monitor for s/s of DHN MIO Administer fluid routinely

 Slow the formula instillation rate to provide time for

CHO and E to be diluted Administer feeding at room temperature, because temp extremes stimulate peristalsis Administer feeding by cont drip rather than by bolus to prevent sudden distention of the intestine Remain in semi fowlers position Instill minimal amount of after needed to flush the tubing before and after feeding, because fluid given with a feeding increases intestinal transit time

 Personal protective equipment

NG/OG tube Catheter tip irrigation 60ml syringe Water-soluble lubricant, preferably 2% Xylocaine jelly Adhesive tape Low powered suction device OR Drainage bag Stethoscope Cup of water (if necessary)/ ice chips Emesis basin pH indicator strips

Explain the procedure and obtain consent 2. Provide a signal for the patient to stop the procedure 3. Sit the patient in a semiupright position with the head supported with pillows and tilted neither backwards nor forwards
1.

 Examine the nostrils for deformity or obstructions to

determine the best side for insertion Measure the tubing from the bridge of the nose to the earlobe, then to the point halfway between the lower end of the sternum and the navel Mark the measured length with a marker or note the distance Lubricate 2-4 inches of tube with lubricant (e.g. 2% Xylocaine)

 Pass the tube via either nostril, past the pharynx, into

the oesophagus and then into the stomach Instruct the patient to swallow and advance the tube as the patient swallows (sipping a glass of water helps) If resistance is met, rotate the tube slowly while advancing downwards. Do not force Stop immediately and withdraw the tube if patient becomes distressed, starts gasping or coughing, becomes cyanosed or if the tube coils in the mouth

 Advance

tube

until

mark

is

reached 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.

 Secure tube with tape or commercially prepared tube

holder If for suction, remove syringe from free end of tube; connect to suction; set machine on type of suction and pressure as prescribed. 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.

- Partially pre-freezing the tube can ease its passage. - Infants can suck on a pacifier during the procedure. - Dont rely on a cuffed endotracheal tube to prevent passage into the trachea be sure and confirm placement using the above methods.

 Do not use force when inserting a NG tube. If

resistance occurs, rotate and retract the tube slightly and try again. Forcing the tube can cause traumatic injury to the tissue of the nose, throat or esophagus.
Always check the tube positioning before giving

feedings. If the tube is out of place the patient may aspirate the feeding solution into the lungs.

 Keep the patient in an upright or semi-upright sitting

position when delivering a tube feeding to enhance peristalsis and avoid regurgitation of the feeding. Check patients who are receiving continuous feedings via a pump or gravity hourly or according to the medical settings policy, to assure that the tube is in position, the formula is flowing at the correct rate and the patient is comfortable with no signs of distention or distress. Cap or clamp off the NG tube when not in use to prevent backflow of stomach contents or accumulation of air in the stomach.

 If

a patient has severe sinus conditions, nasal obstruction or has had facial surgery, it may be necessary to place a oral-gastric tube to avoid further nasal trauma.

 If the amount of gastric aspirate is large prior to a

bolus or intermittent feeding, notify the physician and follow the protocol of the medical setting for reinstilling the gastric aspirate. The feeding size may need to be decreased if the patient is not digesting it.

 If the amount of gastric aspirate is large prior to a

bolus or intermittent feeding, notify the physician and follow the protocol of the medical setting for reinstilling the gastric aspirate. The feeding size may need to be decreased if the patient is not digesting it.

 NG tube placement is meant to be a short-term

solution for feeding problems. Patients that require long term tube feeding should have surgical placement of a gastrostomy tube or gastrostomy button. Longterm NG tube usage can cause nasal erosion, sinusitis, esophagitis, gastric ulceration, esophageal-tracheal fistula formation, oral infections and respiratory infections.

 stop advancing the tube and allow the

patient to rest.

 retract the tubing and try again

 advance the tube between respirations to avoid placing

the tube into the trachea

 remove the tubing, allow the patient to rest

and begin again.

 the tube has passed through the vocal

cords and into the trachea. Remove the tube and start again.

 use a flashlight to look into the patient's

mouth to view the tubing. It should appear straight in the back of the throat with no coiling into the mouth.

 x ray of the abdomen

 Aspirate the stomach contents for residual

formula from the last feeding. If the residual exceeds 100 cc for an adult, hold the feeding and notify the physician. Re-instill the gastric aspirate according to the policy of the medical center or the physician's order. Review the physician's order and select the appropriate type and amount of feeding. Be sure that the patient remains in an upright position during the feeding.

 Shake

prepared formulas before administering them. Formulas that have been refrigerated should be allowed to warm up to room temperature before administering them. To give the feeding using a syringe, remove the barrel from the syringe.

 Open the end of the NG tube and connect it

to the end of the syringe. Pour the feeding into the wide end of the syringe and hold or secure the syringe to the bed or an IV pole just above the patient's head so that it will flow in slowly by gravity over 15-30 minutes. If more feeding is needed than can be held in the syringe, watch the syringe and refill the syringe until the feeding is complete. When the feeding is complete, rinse the tube with 30 cc of water.

 Disconnect and recap the end of the NG

tube and rinse the syringe according to the medical setting's policy. To give an intermittent feeding using a feeding bag, pour the correct feeding amount into the bag and through the tubing connected to the bag down to the tip of the tubing. Clamp the tubing using the roller clamp apparatus. Hang the bag on an IV pole just above the patient's head. Open the NG tube and connect it to the feeding bag tubing.

 end