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Nasogastic tube. 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 tube Discuss administering a tube feeding Discuss Irrigating Nasogastric Tube

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out line
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 tube
  • Discuss administering a tube feeding
  • Discuss Irrigating Nasogastric Tube
  • Explain the procedure.
  • List the potential complications of Nasogastric Tube.
  • Demonstrate the procedure.
introduction
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 tubes
Types of Tubes
  • Short- Nasogastric tube
  • Introduced from the nose to the stomach
  • Levin and Gastric (Salem) Sump
  • Used to remove gas and fluid from the upper GI tract or to obtain a specimen of gastric contents
  • Sometimes used for medications or feedings ( gavage )
levin tube
Levin Tube
  • Single Lumen (hollow part of tube)
  • Size 14-18 French
  • Made of plastic or rubber with opening near tip
  • It is 125 cm long
  • Circular markings on the tube serve as insertion guides
gastric salem sump
Gastric (Salem) Sump
  • Gastric 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

slide7
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 client’s waist.

medium tubes
Medium tubes.
  • Medium length- nasoenteric used for feeding. Example- Dobhoff
  • Placed in the duodenum or jejunum by fluoroscopy (x-ray dept) or at client’s bedside.
  • Verified by x-ray before feedings

begin. May take up to 24 hrs.

  • to pass through the stomach

into the intestines.

  • Place client on right side

to facilitate passage

long nasoenteric tubes
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 fluid
  • Used to (Decompression) to prevent intestinal obstruction.
  • Due to  peristalsis, prevents vomiting, reduces tension at the incision line and prevents obstruction.
long nasoenteric tubes11
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 tubes12
Long- nasoenteric tubes
  • Harris-
  • 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 tubes13
Long- nasoenteric tubes
  • Cantor tube –
  • has a large balloon at distal end of tube. Filled with
  • 4- 5 ml of mercury, water or saline to weight the tube
  • It is 300 cm long
definition
Definition
  • Tube inserted through the nose into stomach
p urposes
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 lungs
  • To establish a means for suctioning stomach contents to prevent gastric distention ,nausea, and vomiting.
  • To remove stomach contents for laboratory analysis
  • To lavage(wash)the stomach in case of poisoning or overdose of medications. 
purposes
Purposes
  • To 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 & 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 nares
Assess the client nares
  • Ask client to hyperextend the head & using flashlight
  • Observe ( intactness of tissue nostrils including any irritation or abrasion )
  • Examine the patient’s nostril for septal deviation. To determine which nostril is more patent, ask the patient to occlude each nostril and breathe through the other
  • Patency of nares & intactness of nasal tissue ( note especially history of nasal surgery or deviated septum )
assess prepare the tube
Assess & prepare the tube
  • If 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
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
equipments22
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) .
  • Tissues
  • Disposable pad & gloves . .
  • Tongue blade .
  • Normal saline solution (for irrigation only).
slide25
Note
  • A 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 tube
Determine how far to insert the tube
  • Measure 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.
insert the tube
Insert the tube
  • Prepare 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 anesthetize
  • Lubricate tip of tube with water soluble lubricant.
  • Ask client to lift head, and insert tube into nostril while directing tube upward and backward.
slide32
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.
slide34

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 placement
Confirming Placement
  • Tube 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.
securing the gi tube
Securing the GI tube
  • Use a skin barrier to prep the skin
  • Use 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 client’s gown with a safety pin.
document
Document
  • Document: Tube type and size
  • Drainage or aspirate (residuals) amount, color and consistency
  • Irrigation type and amount
  • Suction- type and level (i.e. low intermittent)
  • Feeding- type and amount
  • Patient tolerance
  • Patient/ Family education and response
ng suction
NG Suction
  • Tube 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 it’s patent.
  • Record amt. on I&O.
conte
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
Complications
  • The main complications of NG tube insertion :-
  • aspiration and tissue trauma.
  • Placement of the catheter can induce gagging or vomiting, Patient discomfort
  • Epistaxis
  • Pulmonary complication
  • Esophageal perforation
contraindications
Contraindications
  • Absolute contraindications
    • Severe mid face trauma
    • Recent nasal surgery
  • Relative contraindications
    • Coagulation abnormality
    • Esophageal varicose or stricture
    • Alkaline ingestion
tube feedings
Tube Feedings
  • Meet nutritional needs when oral intake not possible
  • Advantageous over TPN
  • GI integrity is preserved
  • Normal insulin/glucagon ratios are maintained
  • Admin. intermittent, continuous
  • Accessed by nasogastric, nasoenteric, gastrostomy or jejunostomy tube
assessment
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 )
purposes49
Purposes:
  • To restore or maintain nutritional status.
  • To administer medications.
equipments50
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
preparation
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
procedure53
Procedure
  • Use 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
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 content
  • Aspirate all stomach content & measure a mount prior to administering the feeding
feeding bag open system
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 system56
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 feeding
Open system ) ) Syringe feeding
  • Remove 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 feeding
Syringe feeding
  • Add 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 tube
  • Cover 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
Documentation:

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

purposes61
Purposes:
  • To clears the tube of feeding or debris.
  • To prevent the spread of microorganisms in the tube of feeding.
equipments62
Equipments:
  • Normal saline solution or water for irrigation.
  • Disposable gloves.
  • Stethoscope.
  • Toomey syringe.
  • Container.
  • Disposable pad.
preparation64
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.
slide65

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.

documentation66
Documentation:
  • Record irrigation procedure, description of drainage, and client's response.
procedure of removing a nasogastric tube
Procedure of Removing a Nasogastric Tube
purposes68
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.
equipments69
Equipments:
  • Tissues.
  • 50-ml syringe (optional).
  • Disposable gloves.
  • Disposable plastic bag.
  • Disposable pad.
  • Normal saline solution or water for irrigation (optional).
  • Emesis basin.
preparation71
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.
slide72

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.

definition of parenteral nutrition
Definition of Parenteral Nutrition

The 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 tpn
Indications for TPN
  • Mall absorption syndromes, such as short bowel syndrome
  • Conditions requiring complete bowel rest for prolonged periods
  • Pre and post-operative support in patients with pre-existing malnutrition, in who GI function is impaired
  • Malignancy undergoing treatment, surgery, radiation, chemo who are unable to obtain adequate nutrition by an enteral route
tpn is generally not indicated
TPN is generally NOT indicated…
  • When an inpatient has a functioning GI tract
  • TPN therapy is expected to be less than 5 days
  • Prognosis does not warrant aggressive nutrition support
source of nutrition
Source of Nutrition
  • Eternal nutrition
  • Parenteral nutrition
    • Central parenteral nutrition (CPN=TPN)
    • Peripheral parenteral nutrition (PPN)
    • Long-term home parenteral

nutrition (HPN)

clinical decision algorithm route of nutrition support
Clinical decision algorithm route of nutrition support

Nutrition Assessment

Decision to institute specialnutrition support

YES

NO

Functional GI Tract

Enteral Nutrition

Parenteral Nutrition

Short-term:

NG, ND,NJ

Long-term:

Gastrostomy Jejunostomy

GI function

TPN

PPN

Intact

Nutrients

Defined

Formula

GI function return

Adequate

Inadequate

Adequate

YES

NO

PN

Oral Feeding

components of tpn
Components of TPN
  • Carbohydrate, Amino acid, Fat, Electrolyte, Water, Vitamin, Trace element
  • Standard solution
    • Dextrose, Amino acid
    • Electrolyte (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
Total Parenteral Nutrition

Normal Diet------------------- TPN

  • Protein--------------------------Amino Acids
  • Carbohydrates------------------Dextrose
  • Fat--------------------------------Lipid Emulsion
  • Vitamins--------------------Multivitamin Infusion
  • Minerals------------------------Electrolytes
  • and Trace Elements
complication
complication
  • Mechanical: thrombosis, embolism, skin slough
  • Infectious: particularly staph epidermidis, Candida
  • Metabolic: hypoglycaemia, hyperglycaemia,

cholestasis