ATI Chapter 54: Nasogastric Intubation & Enteral Feedings – Flashcards

insertion of nasogastric NG tube to manage gastrointestinal dysfunction & provide enteral nutrition -NG tubes, enteral tube feedings can be delivered via jejunal or gastric tubes -Insertion & maintenance of nasogastric/enteral feeding tubes is nurse's responsibility

hollow, flexible, cylindrical device inserted through nasopharynx into stomach

-Removal of gases or stomach contents to relieve distention, nausea, or vomiting -Tube types: Salem sump, Miller-Abbott, Levin

-Route administering nutritional supplements when oral/esophageal passageways cannot be used Tube types: Duo, Levin, Dobbohoff

-Washing out stomach to treat overdose or ingestion of poison Tube types: Eweald, Levin, Salem sump

-Applied pressure using internal balloon to prevent hemorrhage -Tube type- Sengstaken-Blakemore

-Review prescription & purpose, plan for drainage or suction & understand the need for placement for diagnostic purposes -Identify client & explain procedure -Evaluate client's ability to assist and/or cooperate -Perform hand hygiene -Set up equipment: Nasogastric tube- selected according to indication Tape- to secure dressing Gloves Water Soluble lubricant Cup of water & straw Catheter- tipped syringe, usually 30 to 60 mL Basin- to prepare for gag induced nausea pH test strip or meter- to measure gastric secretions for acidity Stethoscope- to check placement Disposable towel- to maintain a clean environment Clamp or plug- to close tubing after insertion Suction apparatus- if continuous or intermittent suction is needed Gauze square- to cleanse outside of tubing after insertion Safety pin and elastic band- to secure tubing & prevent erroneous removal Position a disposable towel & basin Provide privacy

-Nurse may require assistance with clients who are confused or disoriented -Assist client to high-Fowler's position (if possible) -Assess the nares for best position/route: assess whether or not client has had any nasopharyngeal surgery or septal deviation to determine which naris to use -Administer topical anesthetic -Measure tubing- from tip of nose, to top of ear lobe, to tip of the xiphoid, and mark with adhesive tape -Put gloves on -Lubricate tip of tubing -If client is able, have her hold the cup of water with straw in place, and tell her that she will be told when to drink -Have client hyperextend her head back -Gradually insert tube -When resistance is met, apply gentle pressure downward, and proceed beyond curve of nasopharynx -Have client lean her head forward and begin sipping as insertion continues. Swallowing helps feed the tubing downward toward stomach -When tubing reaches mark, anchor the tube suing tape or nasogastric claim -Placement check: Ask client to talk Inspect posterior pharynx for coiled tubing Aspirate gently to collect gastric contents & observe color Test pH (4 or less is expected) Confirm placement with an x-ray as prescribed -Injecting air into tube & when listening over abdomen is not a acceptable practice -If tube is not in stomach, advance it 5 cm & repeat placement check -When placement is confirmed, secure tube to nose using tape -Clamp nasogastric tube or connect it to appropriate suction device -If client vomits, clear airway & provide comfort prior to continuing -Salem sump tubing has a blue pigtail for negative air release. Do not insert any substances into blue pigtail, as it will break seal and tubing will leak

The insertion & maintenance of nasogastric tube is nursing responsibility; but measuring output, providing comfort, & giving oral care can be delegated

-Inform client of order & process, emphasizing that removal is less stressful than placement -Perform hand hygiene & don gloves -Remove safety pin from gown, & remove tape-anchoring tube to nose -Disconnect tubing from suction & claim it -Provide facial tissues for client -Instruct client to take & hold deep breath -Remove tubing with steady continuous pull while client is hold her breath -Measure & record any drainage -Clean nares & provide oral care -Ensure client is confortable -Dispose of equipment -Document all relevant information including: Tubing removal & condition of tube Volume & description of drainage Abdominal assessment, including inspection, auscultation, palpation, & percussion -Last & next bowel movement & urine output

Excoriation (tear or strip) of nares & stomach -Apply lubricant to nares as needed -Assess color of nasogastric tube drainage. Report dark "coffee-ground" or blood-streaked drainage to provider immediately Discomfort -Rinse client's mouth with water for dryness -Throat lozenges may be helpful -Provide oral hygiene frequently Occlusion (Obstruction) of NG tube leading to distention -Irrigate tube per facility protocol to unclog blockages. Tap water may be used with enteral feedings. Have client change position in case tube is against stomach wall

is a method of providing nutrients to clients who cannot consume foods orally; Enteral Formulas:

1.0 to 2.0 kcal/mL; milk-based, blenderized foods

formulas prepared by hospital dietary staff or commercially prepared; nutritionally complete -Only used if client's GI can absorb whole nutrients

3.8 to 4.0 kcal/mL predigested nutrients -Not nutritionally complete; provide a single macronutrient -Easier for partially dysfunctional GI tract to absorb

-Not nutritionally complete -Primarily for clients who have hepatic failure, respiratory disease, or HIV infection

Therapy duration shorter than 4 weeks; Inserted via nose

therapy duration longer than 4 weeks; Inserted surgically

therapy duration longer than 4 weeks; Inserted endoscopically

* Surgical & endoscopic insertion presents an increased risk or injury & infection; therefore, they are only indicated for long-term use *Gastroparesis, esophageal reflux, or history of aspiration pneumonia generally requires intestinal placement*

*Nursing Actions: Preparation of Client -Review client's prescription: PCP usually determines the type of tube feeding formula in consultation with dietary staff -Set up equipment -Feeding bag -Tubing -30 to 60 mL syringe (compatible with tubing) -Stethoscope -pH indicator strip -Infusion pumps (if not a gravity drip_ -Appropriate enteral formula -Irrigation solution or tap water, according to facility policy -Gloves -Supplies for blood glucose (if protocol or orders indication)

Prepare formula, tubing, & infusion device -Check expiration dates & note content of formula -Assure formula is at room temperature -Setup feeding system via gravity or pump -Mix or shake formula, fill container, prime tubing, and clamp it Assist client to Fowler's position or elevate head of bed to minimum of 30 Monitor Tube Placement -Check gastric contents for pH. Good indication of appropriate placement is obtaining gastric contents with pH between 0 & 4 -Aspirate for residual volume; intestinal residual should be less than 10 mL, & gastric residual less than 100 mL -Note appearance of aspirate -Return aspirated contents or follow facility protocol Flush tubing with 30 to 60 mL of tap H20 Administer formula Intermittent feeding: have formula & a 60 mL syringe prepared -Remove plunger from syringe -Hold tubing above instillation site -Open stopcock on tubing, and insert barrel of syringe with end up -Fill syringe with 40 to 50 mL of formula -If using a feeding bag, fill bag with total amount of formula prescribed for one feeding, and hang it to drain via gravity until empty (about 30 min) -If using syringe, hold it high enough for formula to empty gradually via gravity -Continue to refill syringe until amount prescribed for feeding is instilled -Follow with 60 to 100 mL of tap water (or amount prescribed) to flush tube & prevent clogging

-Connect feeding bag system to feeding tube -If using a pump, program the instillation rate as prescribed, and set the total volume to instill -Start pump -Flush enteral tubing with 30 to 60 mL of irrigant, usually tap water, every 4 to 6 hr, and check tube placement again -Monitor intake & output & include 24 hr. totals -Monitor capillary blood glucose every 6 hrs. until max administration rate is reached & maintained for 24 hrs. -An infusion pump is required for intestinal tube feedings -Follow manufacturer's recommendations for formula hang time. Unused formula should be refrigerated & discarded after 24 hrs. -Gastric residual should be checked every 4 to 8 hr. Facility protocol specifies the actions to take based on amount of residual obtained -Delegation of this skill to assistive personnel is INAPPROPRIATE

*When gastric residuals exceeds 100 mL (10 mL for intestinal placement) -Withhold feeding -Notify provider -Maintain semi-Fowler's position -Recheck residual in 1 hr or as prescribed *Diarrhea 3 times or more in 24-hr period -Notify provider -Confer with dietitian -Provide skin care & protection *Nausea or Vomiting -Withhold feeding -Turn client to side* -Notify provider -Aspirate for residual -Auscultate for bowel sounds Aspiration of formula -Withhold feeding -Turn client to side -Suction airway -Provide O2 if indicated -Monitor client's vital signs for elevated temperature -Auscultate breath sounds for increased congestion -Notify the provider -Obtain chest x-ray Skill irritation around tubing site -Provide skin barrier from any drainage at site -Monitor tube's placement

A

B

B

A, B, C

A, B