Intermediate Nursing 1.3 Nasogastric Tubes – Flashcards

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components of the alimentary canal and their functions

the purpose for nasogastric tube insertion

the anatomy and physiology of the digestive system associated with the placement, maintenance and removal of a nasogastric tube

equipment used for insertion, maintenance and discontinuation of a nasogastric tube

the procedure for inserting a nasogastric tube and checking its placement

patient care and nasogastric tube maintenance needs

the procedure for removal of nasogastric tube

the procedure for recording nasogastric tube insertion, irrigation, removal, and feeding

The internal application of pressure by means of an inflated balloon to prevent internal esophageal or gastrointestinal hemorrhage

Gavage Lavage

The removal of secretions and gaseous substances from a patient's gastrointestinal tract; prevention or relief of abdominal distention

Difficulty swallowing

Instillation of liquid nutritional supplements or feedings into the stomach for patients unable to swallow

Unit of measurement for catheters designed to be inserted into preexisting orifices. 1 French (Fr.) = 1/3 mm

parts D J S

The administration of nourishment through a stomach tube

Intake and Output

Occurring at intervals; not consistent

The irrigation of the stomach in cases of active bleeding, poisoning or gastric dilation

tube inserted into the nose to end in the stomach

The components of the alimentary canal (tract) are the mouth, pharynx, esophagus, stomach, small intestine, and large intestine

The oral cavity where digestion begins

Glands located in the mouth produce saliva, which perform the following functions: o Lubricates the mouth cavity and food mass o Dissolves soluble food, stimulating the taste buds o Begins the chemical breakdown of food

o Lubricates the mouth cavity and food mass o Dissolves soluble food, stimulating the taste buds o Begins the chemical breakdown of food

The passageway between the mouth and the esophagus that is shared with the respiratory system

A lid-like flap that covers the entrance to the trachea, separating the trachea from the pharynx

A muscular tube that carries chewed food by peristalsis to the stomach

A ring of smooth muscle that prevents food and gastric juices from leaving the stomach and traveling back up the esophagus

A pouch-shaped organ that receives food from the esophagus through the cardiac sphincter that is located between the lower end of the esophagus and the first portion of the small intestine

as a food reservoir: Very little absorption of substances occurs in the stomach Alcohol is absorbed

produced by glands in the stomach wall Mixture of partially digested food and digestive enzymes is called chyme The stomach periodically releases chyme to the small intestine through the pyloric sphincter

A ring of smooth muscles that prevents partially digested material from reentering the stomach

A membrane that lines the abdominal cavity

Structure where the greatest amount of chemical digestion and food absorption occurs

1. Duodenum - C-shaped 2. Jejunum 3. Ileum - Empties into the large intestines

are finger-like projections that absorb digested food particles

are emulsified in the small intestine

occurs by segmentation: Stimulates strictly localized contractions in the areas of the small intestine containing chime Mixes chyme with digestive juices and brings the particles in contact with mucosa for absorption Does not push the contents along the digestive tract; only mixes chyme with digestive juices Chyme is propelled through the small intestine by peristalsis

Chyme is propelled through the small intestine by peristalsis

Receives watery food residue from the small intestine

include: Storage of chyme Completion of absorption Formation of feces Expulsion of feces

Cecum - Blind pouch; where the appendix is attached Colon - Divided into four parts: ascending colon, transverse colon, descending colon, and sigmoid colon Rectum Anal canal

NG tubes are inserted with a Doctor's order and are primarily used for introduction of food and fluids through a tube when a patient is unable to eat and drink normally.

Temporary nutritional support Excessive vomiting Stomach decompression Patients at risk for aspiration Dysphagia

Medication administration Irrigation Removal of fluids, gas and poisons (e.g., drug overdose) Diagnostic tests (e.g., gastric analysis)

12 Fr. and above, are usually used for gastric decompression or removal of gastric secretions.

are frequently used for medication administration and enteral feedings.

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have an impact on the digestive system.

NG tube travels from one of the nares, through the nasal mucosa, pharynx, esophagus, cardiac sphincter and into the stomach.

constant irritation, inflammation and skin tearing to the nasal mucosa Occlude the NasoPharyngeal Airway

will help minimize irritation to the nasal mucosa Sore throats are common, ice bag application and Xylocaine gargles will help discomfort.

Mouth care every two hours

NG tubes are plastic or rubber Adhesive tape Curved basin Glass of water Toomey syringe Chux pad Rubber band Safety pin Stethoscope Straw Tissues Water soluble lubricant Gloves Penlight Tongue blade

Comes in sizes 10 Fr., 12 Fr., 14 Fr., 16 Fr. Most common sizes for adults are 14 or 16 Fr.

Single lumen; most commonly used for stomach decompression Rubber tubes can be placed in ice water to firm tube. Plastic tubes can be placed in warm water if too stiff

can be placed in ice water to firm tube.

Can be placed in Warm Water if too Stiff

Double-lumen tube; also used for stomach decompression, preferable to Levin type. (Note: Never clamp off the air vent, connect it to suction or use it for irrigation)

8-10 Fr., commonly referred to as Dobhoff tubes

Always verify local protocol as to who can insert a feeding tube

does not require sterile technique. Clean technique is used.

Verify doctor's orders Perform patient identification checks using two identifiers Gather equipment and take to bedside Perform hand hygiene and don gloves Ask patient if they have a latex allergy Explain procedure to patient Provide for privacy, safety, and comfort Place the patient in High-Fowler's position as tolerated. Place pillows behind head and shoulders. Patient may retch or vomit. Sitting position facilitates the tubes passage. Remove dentures if present Raise the bed to a comfortable working level Have a 4-inch (10-cm) piece of tape ready with one end split in half lengthwise Place a clean towel over the patient's chest and provide the patient with facial tissues. Allow the patient to blow his or her nose if necessary Place emesis basin within reach Clean the bridge of the patient's nose with soap and water or an alcohol swab Examine nostrils with penlight for possible obstruction or deformities. May also have patient breathe through one nostril while occluding the other to assess air flow. If both nostrils are obstructed, notify the nurse or physician. Ask patient if he/she has ever had a broken nose or been diagnosed with a deviated septum Determine the length to insert the nasogastric tube o Measure from the tip of the nose to earlobe and from earlobe to end of xiphoid process o Mark this distance on tube with small piece of tape Curve 4 to 6 inches of end of tube tightly around your index finger, then release Lubricate 3 to 4 inches of the end of the tube with water-soluble lubricating jelly Alert the patient when the procedure is about to begin Instruct the patient to extend the neck back against a pillow; insert the NG tube gently through the nare at an angle parallel to the floor of the nasal canal, not upright. If the tip has a curve, point the curved end downward (fig. 5) Continue to pass the tube along the floor of the nasal passage, aiming down toward the patient's ear. If resistance is felt, apply gentle downward pressure to advance the tube If resistance continues, try to rotate and then advance the tube. If resistance persists, withdraw the tube, allow the patient to rest, lubricate the tube again, and insert the tube into the other nare. Do not force past resistance Continue inserting the tube until it is just past the nasopharynx by gently rotating the tube toward the opposite nare Once past the nasopharynx, stop tube advancement, allow the patient to relax, and provide tissues, unless the patient would prefer to avoid delay Explain to the patient that the next step requires the patient to swallow. Give the patient a glass of water unless contraindicated With the tube just above the oropharynx, instruct the patient to flex his or her head forward (say, "Look at your toes" or "Tuck your chin to your chest"), take a small sip of water (if swallow is felt to be safe and the patient is able to cooperate), and swallow Advance the tube with swallowing If the patient begins to cough, gag, or choke, withdraw the tube to the nasopharyngeal area and stop advancement If vomiting occurs, assist the patient to clear his or her airway. Perform oral suctioning as needed Advance until reaching the tape or mark on the tube that signifies that the tube is inserted the desired distance Anchor the tube to the patient's cheek with tape until tube placement has been verified

Verify doctor's orders Perform patient identification checks using two identifiers Gather equipment and take to bedside Perform hand hygiene and don gloves Ask patient if they have a latex allergy

Explain procedure to patient Provide for privacy, safety, and comfort Place the patient in High-Fowler's position as tolerated. Place pillows behind head and shoulders. Patient may retch or vomit. Sitting position facilitates the tubes passage. Remove dentures if present Raise the bed to a comfortable working level Have a 4-inch (10-cm) piece of tape ready with one end split in half lengthwise Place a clean towel over the patient's chest and provide the patient with facial tissues. Allow the patient to blow his or her nose if necessary Place emesis basin within reach Clean the bridge of the patient's nose with soap and water or an alcohol swab Examine nostrils with penlight for possible obstruction or deformities. May also have patient breathe through one nostril while occluding the other to assess air flow. If both nostrils are obstructed, notify the nurse or physician. Ask patient if he/she has ever had a broken nose or been diagnosed with a deviated septum

Determine the length to insert the nasogastric tube o Measure from the tip of the nose to earlobe and from earlobe to end of xiphoid process o Mark this distance on tube with small piece of tape Curve 4 to 6 inches of end of tube tightly around your index finger, then release Lubricate 3 to 4 inches of the end of the tube with water-soluble lubricating jelly Alert the patient when the procedure is about to begin Instruct the patient to extend the neck back against a pillow; insert the NG tube gently through the nare at an angle parallel to the floor of the nasal canal, not upright. If the tip has a curve, point the curved end downward (fig. 5) Continue to pass the tube along the floor of the nasal passage, aiming down toward the patient's ear. If resistance is felt, apply gentle downward pressure to advance the tube If resistance continues, try to rotate and then advance the tube. If resistance persists, withdraw the tube, allow the patient to rest, lubricate the tube again, and insert the tube into the other nare. Do not force past resistance Continue inserting the tube until it is just past the nasopharynx by gently rotating the tube toward the opposite nare

Once past the nasopharynx, stop tube advancement, allow the patient to relax, and provide tissues, unless the patient would prefer to avoid delay Explain to the patient that the next step requires the patient to swallow. Give the patient a glass of water unless contraindicated With the tube just above the oropharynx, instruct the patient to flex his or her head forward (say, "Look at your toes" or "Tuck your chin to your chest"), take a small sip of water (if swallow is felt to be safe and the patient is able to cooperate), and swallow Advance the tube with swallowing If the patient begins to cough, gag, or choke, withdraw the tube to the nasopharyngeal area and stop advancement If vomiting occurs, assist the patient to clear his or her airway. Perform oral suctioning as needed Advance until reaching the tape or mark on the tube that signifies that the tube is inserted the desired distance Anchor the tube to the patient's cheek with tape until tube placement has been verified

Three methods to verify tube's placement in stomach. Placement is checked after insertion, before anything is introduced into the NG tube and usually at the beginning of each shift:

Attach a large syringe to free end of NG tube. Not to air vent which is the blue tubing Aspirate for stomach content, approximately 10 to 30 mL. When tube is correctly placed, stomach fluids will return in tube Observe color and volume, contents are usually cloudy and green Measure aspirate for pH with color-coded pH indicator strip

Aspirate 20-30 mL of air into a large syringe Attach the syringe to the end of the gastric tube Place stethoscope over the left upper quadrant of the abdomen immediately below rib margin Inject air rapidly through the tubing A "swooshing" sound is heard if the tube is in the stomach

is a chest X-ray

Cap or clamp the tube until connected to drainage Apply a small amount of tincture of benzoin or skin preparation agent to the lower end of the patient's nose and allow to dry before taping the tube to the nose Apply prepared tape to the nose, leaving split ends free. Be sure the tape over the nose is secure. Carefully wrap two split ends of tape around the tube Attach tube to patient's gown by placing tape around tube and pinning tape to gown. Leave room for head movement Connect tube to suction as ordered Elevate the head of the bed 30 degrees Explain to the patient that the discomfort from the tube should decrease with time

Connect tube to suction

Elevate the head of the bed

the discomfort from the tube should decrease with time

Doff gloves and perform hand hygiene

Record procedure, pertinent observations and patient's response on SF 510 and DD Form 792

Make certain of correct tube placement and tape the tube to the patient's nose, taking care not to apply pressure on the nostrils. Excess pressure will cause ulceration Secure the tubing to the patient's clothing to prevent accidental removal of the tube

Observe tubing for movement of gastric contents along tubing Check drainage collection bottle to see if drainage is collecting

Inform nurse If directed, the Corpsman/Technician may perform Interventions

o Move the tube "in and out" 1-2 inches to determine whether or not the end of the tube is above or below the fluid level in the stomach. Suction may cause tube to adhere to stomach wall o "Milk" the tube to assist thick secretions to move along in the tube o Irrigate the tubing, as ordered. Repeat until tubing is clear o Note contents for color, odor and consistency

Gargles and lozenges Lubricant to nares Offer mouth care. Patient may brush teeth with NG tube in place. Caution not to swallow water Alter tape position PRN to protect skin integrity Tincture of benzoin may be used to protect the skin Explain pertinent instructions to patient (e.g., NPO status) Provide psychological support

Perform hand hygiene and don clean gloves Perform patient identification checks using two patient identifiers Explain procedure to patient Provide for safety, privacy, and comfort

o Check expiration date on formula and integrity of container o Ensure tube-feeding formula is at room temperature o Connect tubing of administration set to container, or prepare ready-to-hang container o Use aseptic technique, and avoid contaminating the feeding system. If administering canned formula, wipe top with alcohol swab before opening and pouring into administration bag o Shake formula container well, and fill feeding container bag with formula. Pour only the amount needed for 8 hours o Label bag with tube-feeding type, strength, and amount. Include date, time, and initials. Do not dilute or add additives to the tube feeding formula o Open roller clamp on tubing, and fill tubing (prime tubing) with formula. Close roller clamp, and cap end of tubing o Label administration set "Tube feeding only" o Hang bag on feeding pump pole

Position patient in High Fowler's position. Head of bed remains elevated during the feeding and for 30 min afterwards to decrease the risk of regurgitation and aspiration. Gravity helps the flow of formula Verify tube placement Place Chux pad under tube to protect patient and bed

o Record residual on the 24 Hour Intake and Output Worksheet (DD Form 792). o If aspirate is more than half of previous feeding or more than 150 mL, notify nurse before administering feeding. Indicates previous feeding was not tolerated well and amount may require modification

Connect the clamped feeding setup to the feeding tube. Always administer feeding at room temperature to avoid cramping and diarrhea Unclamp the tubing and adjust flow rate, per orders For intermittent feeding, adjust flow rate by raising/lowering the feeding setup and/or adjusting regulator on tubing. Infusion pumps can be used (Kangaroo pumps) Allow bag to empty gradually over 30-60 minutes

may also be administered on a continuous basis. Check tube feeding bag every 4 - 6 hours or per local protocol, for signs of spoilage

Following intermittent infusion or every 4 hours throughout continuous infusion

Clamp tubing and/or cap the free end of the feeding tube

on Nursing Notes SF 510 and Twenty-Four Hour I & O Worksheet DD Form 792

is performed to ensure patency of the tube.

Check doctor's order for frequency of irrigation, amount and type of solution Gather Supplies: o Stethoscope o 60mL syringe o Irrigation fluid (e.g. coke, normal saline (NS), sterile water) o Non-sterile gloves Perform hand hygiene and don gloves Verify the correct patient using two identifiers Explain the procedure to the patient Elevate head of bed to a 30 degree angle Place a clean towel under the NG tube and tubing connection Check placement of NG tube Fill syringe with 30 mL of ordered solution

o Stethoscope o 60mL syringe o Irrigation fluid (e.g. coke, normal saline (NS), sterile water) o Non-sterile gloves

Date and Time procedure was done Type and size of NG tube Nare used (left or right) Character, color, odor, consistency and amount of contents Any difficulties with insertion Patient's tolerance of procedure Instructions given to patient Whether attached to suction (type), feeding or clamped

"Date/Time. 14 Fr. Salem Sump tube inserted into right nare without difficulty. 100 mL of light green, thick odorless drainage returned. Tolerated procedure without complaint. Instructed on NPO status. NG tube attached to low intermittent suction. ----Signature/Rate or Rank."

Date and time procedure was performed Type and amount of irrigation solution used Aspirated contents: color, odor, character, consistency and amount Patient's tolerance of procedure Comfort measures performed

"Date/Time. NG tube irrigated with 30 mL NS. Aspirated 30 mL pale green, odorless, thick fluid. Tolerated procedure without complaint. Vaseline applied to right nare. Assisted with oral hygiene. ---Signature/Rate or Rank."

Drainage: color, odor, character, consistency, and amount Condition of skin (nose) Patient's tolerance Patient education

"Date/Time. 14 Fr. Salem Sump tube removed from RT nare, 200 mL dark, green, thick, odorless drainage noted. Tolerated procedure without complaint. No skin breakdown noted to nares. Oral hygiene provided. Reviewed NPO status. ---Signature/Rate or Rank."

Type and amount of tube feeding Rate of administration Patient's response

"Date/Time. Administered 250 mL of Ensure at 50 mL/hour, tolerated without c/o nausea. ---Signature/Rate or Rank."

Intake - All gavage feedings and irrigations: o Date and time o Type of solution o Amount instilled Output - Any drainage collected in suction bottle and any aspirated contents following irrigation: o Date and time o Description of drainage o Amount

Verify DO's Verify Pt c 2 IDs HH & BSI/PPE Ask Pt Allergies to latex Explain Procedure Provide Pt Privacy

Place in HIGH FOWL Pos. Exam NP & Select patent by having Pt. Occlude & Blow out nostril MEASURE Appropriate LENGTH: Tip of Nose to Earlobe to Xyphoid Process of Sternum. CURVE AROUND digit and LUBRICATE 3-4 inches with Water Soluble Lube Jelly.

ALERT PT: Procedure is about to Begin INSERT NG: Gently thru NARE at Angle Parallel to Floor of Nasal Canal, Curved End pointing Downward ADVANCE: c Swallowing, until TAPE Reached. ATTACH: Toomey Syringe to free end. INJECT: 20-30 mL of air for SWOOSH SOUND. ASPIRATE: 10-30 mL of Gastric Contents.

ATTACH/APPLY: TAPE to NOSE; split end free. Wrap 2 split ends around tube. SECURE: TUBE c TAPE pinned to Pt. gown or bed linen c Slack f HEAD MOVEMNT. CONNCT TUBE & SUCT.: as Ordered. Doff. PPE/BSI and HH. DOC.: on SF 510

Temporary nutritional support Excessive vomiting Stomach decompression Patients at risk for aspiration Dysphagia

Medication administration Irrigation Removal of fluids, gas and poisons Diagnostic tests

Irritation Inflammation Skin tearing Mouth breathing Sore throat

Levin Salem sump Weighted feeding tube

NG Tubes Adhesive tape Curved basin Glass of water Toomey syringe Chux pad Rubber band Safety pin Stethoscope Straw

Verify patient is not allergic to latex Position patient Measure and mark tube Lubricate, then insert to marking

Aspirate 10-30 mLs Auscultate 20-30 mLs X-ray

Check placement Secure tube to nose and gown Connect tube to suction as ordered Record procedure

Check NG tube Placement Function Patency

Notify nurse Move the tube Milk the tube Irrigate

Gargles and lozenges Lubricant to nares Brush teeth Reposition tape as needed Patient education Psychological support

Prepare feeding container Position patient Check tube placement Aspirate residual feeding Administer feeding at room temperature Intermittent infusion runs gradually over 30-60 mins Check continuous feeding every 4-6 hrs for spoilage Following intermittent feeding or every 4 hrs during continuous feeding, flush tubing with 30 mL water Clamp tubing after feeding Offer oral/nasal hygiene Record procedure

Check doctor's order !. Frequency @. Amount #. Type of solution Gather supplies Position patient Check placement Increments of 30mL Aspirate to withdraw fluid Flush with 10mL air and reconnect Document procedure

Verify Doctor's orders and patient identity Position patient Disconnect from suction or drainage Flush with 20mL air Clamp or kink tubing Remove NG tube with smooth steady motion Inspect tubing Offer oral / nasal hygiene Measure drainage amount

Color Consistency Character Then Document procedure

Date and Time Tubing Nare used Contents Difficulties Patient tolerance Patient education Disposition of tubing

Color Odor Character Consistency

Date and time Type and amount of solution Aspirated contents Patient tolerance Comfort measures

Drainage Skin condition Patient tolerance Patient education

Type of feeding and amount Infusion rate Patient response

Feeding time Continued

To Clean Tube

After Feeding

Insure the Patency of NG Tube

Gavage feeding Irrigation

Until Amnt DO is reached

Drainage Aspirated contents

goes in before taking out To Clear out