Fundamental Fundamental NursingNursing

Chapter 29Chapter 29

Gastrointestinal Gastrointestinal

IntubationIntubation

2

Clients, especially those undergoing abdominal or Clients, especially those undergoing abdominal or gastrointestinal (GI) surgery, may require some type of tube gastrointestinal (GI) surgery, may require some type of tube placed within their stomach or intestine. Use of a gastric or placed within their stomach or intestine. Use of a gastric or intestinal tube reduces or eliminates problems associated with intestinal tube reduces or eliminates problems associated with surgery or conditions affecting the GI tract such as impaired surgery or conditions affecting the GI tract such as impaired peristalsis, vomiting, or gas accumulation. Tubes also can peristalsis, vomiting, or gas accumulation. Tubes also can

nourish clients who cannot eat.nourish clients who cannot eat.

This chapter discusses the multiple uses for gastric and This chapter discusses the multiple uses for gastric and intestinal tubes and the nursing guidelines and skills for intestinal tubes and the nursing guidelines and skills for managing associated client care. managing associated client care.

3

Intubation

IntubationIntubation generally means the placement of generally means the placement of a tube into a body structure; in this chapter, it a tube into a body structure; in this chapter, it refers specifically to insertion of a tube into refers specifically to insertion of a tube into the stomach or intestine by way of the mouth the stomach or intestine by way of the mouth or nose. or nose.

4

Orogastric intubationOrogastric intubation (insertion of a tube through (insertion of a tube through the mouth into the stomach), the mouth into the stomach), nasogastric intubationnasogastric intubation (insertion of a tube through the nose into the stomach; (insertion of a tube through the nose into the stomach; Fig. 29-1), and ), and nasointestinal intubationnasointestinal intubation (insertion (insertion of a tube through the nose to the intestine) are of a tube through the nose to the intestine) are performed performed to remove gas or fluids or to administer to remove gas or fluids or to administer liquid nourishment.liquid nourishment.

5Figure 29-1 • Nasogastric intubation pathway.

6

A tube also may be inserted within an A tube also may be inserted within an ostomyostomy (surgically created opening). A prefix (surgically created opening). A prefix identifies the anatomic site of the ostomy; for identifies the anatomic site of the ostomy; for instance, a “instance, a “gastrostomy” is an artificial is an artificial opening into the stomach opening into the stomach

7

Gastric or intestinal tubes are used for a variety of Gastric or intestinal tubes are used for a variety of reasons, including the following:reasons, including the following:

Performing a Performing a gavagegavage (providing nourishment) (providing nourishment) Administering oral medications that the client cannot Administering oral medications that the client cannot

swallowswallow Obtaining a sample of secretions for diagnostic testingObtaining a sample of secretions for diagnostic testing Performing a Performing a lavagelavage (removing substances from the (removing substances from the

stomach, typically poisons)stomach, typically poisons) Promoting Promoting decompressiondecompression (removing gas and liquid (removing gas and liquid

contents from the stomach or bowel)contents from the stomach or bowel) Controlling gastric bleeding, a process called compression Controlling gastric bleeding, a process called compression

or or tamponadetamponade (pressure) (pressure)

8

Types of Tubes

Although all gastric and intestinal tubes have a Although all gastric and intestinal tubes have a proximal and distal end, their size, proximal and distal end, their size, construction, and composition vary according construction, and composition vary according to their use (to their use (Table 29-1). ).

Tubes can be identified according to the Tubes can be identified according to the location of their insertion (mouth, nose, or location of their insertion (mouth, nose, or abdomen) or the location of their distal end abdomen) or the location of their distal end (stomach [gastric] or intestinal).(stomach [gastric] or intestinal).

9

10

11

1 .Orogastric Tubes

An An orogastric tubeorogastric tube (tube inserted at the (tube inserted at the mouth into the stomach), such as an Ewald mouth into the stomach), such as an Ewald tube, is used in an emergency to remove toxic tube, is used in an emergency to remove toxic substances that have been ingested. The substances that have been ingested. The diameter of the tube is large enough to remove diameter of the tube is large enough to remove pill fragments and stomach debrispill fragments and stomach debris

12

2 .Nasogastric Tubes

A A nasogastric tubenasogastric tube (tube placed through the (tube placed through the nose and advanced to the stomach) is smaller nose and advanced to the stomach) is smaller in diameter than an orogastric tube but larger in diameter than an orogastric tube but larger and shorter than a nasointestinal tube. Some and shorter than a nasointestinal tube. Some nasogastric tubes have more than one nasogastric tubes have more than one lumenlumen (channel) within the tube. with multiple uses: (channel) within the tube. with multiple uses: decompressiondecompression to remove fluid and gas from to remove fluid and gas from the stomach the stomach

13

Because nasogastric tubes remain in place for several Because nasogastric tubes remain in place for several days or more, many clients complain of nose and days or more, many clients complain of nose and throat discomfort. throat discomfort.

Furthermore, gastric tubes tend to dilate the Furthermore, gastric tubes tend to dilate the esophageal sphincter, esophageal sphincter,

The stretched opening may contribute to The stretched opening may contribute to gastric gastric refluxreflux (reverse flow of gastric contents), If gastric (reverse flow of gastric contents), If gastric reflux occurs, the liquid could enter the airway and reflux occurs, the liquid could enter the airway and interfere with respiratory function. interfere with respiratory function.

14

3 .Nasointestinal Tubes

Nasointestinal tubesNasointestinal tubes (tubes inserted through (tubes inserted through the nose for distal placement below the the nose for distal placement below the stomach) are longer than their gastric stomach) are longer than their gastric counterparts.counterparts.

They are used to provide nourishment (feeding They are used to provide nourishment (feeding tubes) or to remove gas and liquid contents tubes) or to remove gas and liquid contents from the small intestine (decompression from the small intestine (decompression tubes). tubes).

15

4 .Transabdominal Tubes

Transabdominal tubesTransabdominal tubes (tubes placed through (tubes placed through the abdominal wall) provide access to various the abdominal wall) provide access to various parts of the GI tract. Two examples are a parts of the GI tract. Two examples are a gastrostomy tubegastrostomy tube or G-tube (transabdominal or G-tube (transabdominal tube located within the stomach)tube located within the stomach)

A gastrostomy tube is placed surgically or A gastrostomy tube is placed surgically or with the use of an endoscope. (with the use of an endoscope. (Fig. 29-4A). ).

16

Figure 29-4 • Transabdominal tubes. (A ) Percutaneous endoscopic gastrostomy (PEG) tube. (B ) Percutaneous endoscopic jejunostomy (PEJ) tube

17

Nasogastric Tube Management

Usually nurses insert nasogastric tubes. Usually nurses insert nasogastric tubes. Additional nursing responsibilities include Additional nursing responsibilities include keeping the tube patent (or unobstructed), keeping the tube patent (or unobstructed), implementing the prescribed use, and implementing the prescribed use, and removing the tube when it has accomplished removing the tube when it has accomplished its therapeutic purpose.its therapeutic purpose.

18

InsertionInsertion

Inserting a nasogastric tube involves preparing Inserting a nasogastric tube involves preparing the client, conducting preintubation the client, conducting preintubation assessments, and placing the tube.assessments, and placing the tube.

19

Client PreparationClient Preparation

Most clients are anxious about having to Most clients are anxious about having to swallow a tube.swallow a tube.

Explaining the procedure and giving Explaining the procedure and giving instructions on how the client can assist while instructions on how the client can assist while the tube is being passed may further reduce the tube is being passed may further reduce anxiety. anxiety.

20

Preintubation AssessmentPreintubation Assessment

Level of consciousnessLevel of consciousness WeightWeight Bowel soundsBowel sounds Abdominal distentionAbdominal distention Integrity of nasal and oral mucosaIntegrity of nasal and oral mucosa Ability to swallow, cough, and gagAbility to swallow, cough, and gag Any nausea and vomitingAny nausea and vomiting

21

One main goal of the assessment is to One main goal of the assessment is to determine which nostril is best to use when determine which nostril is best to use when inserting the tube and the length to which the inserting the tube and the length to which the tube will be inserted. tube will be inserted.

22

Nasal InspectionNasal Inspection

the nurse inspects each nostril for size, shape, the nurse inspects each nostril for size, shape, and patency. The client should exhale while and patency. The client should exhale while each nostril in turn is occluded. The presence each nostril in turn is occluded. The presence of nasal polyps (small growths of tissue), a of nasal polyps (small growths of tissue), a deviated septum (nasal cartilage deflected deviated septum (nasal cartilage deflected from the midline of the nose), or a narrow from the midline of the nose), or a narrow nasal passage excludes a nostril for tube nasal passage excludes a nostril for tube insertion. insertion.

23

Tube MeasurementTube Measurement

before inserting a tube, the nurse obtains the before inserting a tube, the nurse obtains the client's client's NEX measurementNEX measurement (length from nose (length from nose to earlobe to the xiphoid process [tip of the to earlobe to the xiphoid process [tip of the sternum]; sternum]; Fig. 29-5) and marks the tube ) and marks the tube appropriately. appropriately.

24

The first mark on the tube is made at the The first mark on the tube is made at the measured distance from the nose to the measured distance from the nose to the earlobe. It indicates the distance to the nasal earlobe. It indicates the distance to the nasal pharynx, a location that places the tip at the pharynx, a location that places the tip at the back of the throat but above where the gag back of the throat but above where the gag reflex is stimulated. A second mark is made at reflex is stimulated. A second mark is made at the point where the tube reaches the xiphoid the point where the tube reaches the xiphoid process, indicating the depth required to reach process, indicating the depth required to reach the stomach.the stomach.

25Obtaining the NEX measurement

26

Tube PlacementTube Placement

When inserting a nasogastric tube, the nurse's When inserting a nasogastric tube, the nurse's primary concerns are to cause as little primary concerns are to cause as little discomfort as possible, to preserve the discomfort as possible, to preserve the integrity of the nasal tissue, and to locate the integrity of the nasal tissue, and to locate the tube within the stomach, not in the respiratory tube within the stomach, not in the respiratory passages.passages.

Once the tube is at its final mark, the nurse Once the tube is at its final mark, the nurse must verify the location within the stomach. must verify the location within the stomach.

27

The physical assessment methods that nurses use to methods that nurses use to determine the distal location of a nasogastric tube are determine the distal location of a nasogastric tube are as follows: as follows:

Aspirating fluid: If aspirated fluid appears clear, brownish-Aspirating fluid: If aspirated fluid appears clear, brownish-yellow, or green, the nurse can presume that its source is yellow, or green, the nurse can presume that its source is the stomach (the stomach (Fig. 29-6).).

Auscultating the abdomen: The nurse instills 10 mL or Auscultating the abdomen: The nurse instills 10 mL or more of air while listening with a stethoscope over the more of air while listening with a stethoscope over the abdomen. If a swooshing sound is heard, the nurse can abdomen. If a swooshing sound is heard, the nurse can infer that the cause was air entering the stomach. Belching infer that the cause was air entering the stomach. Belching often indicates that the tip is still in the esophagus.often indicates that the tip is still in the esophagus.

28

Figure 29-6 • Aspirating gastric fluid.

29

Testing the pH of aspirated liquid: The first two Testing the pH of aspirated liquid: The first two techniques provide only presumptive signs that the techniques provide only presumptive signs that the tube is in the stomach; testing pH confirms acidic tube is in the stomach; testing pH confirms acidic gastric contents. Other than obtaining an abdominal x-gastric contents. Other than obtaining an abdominal x-ray, the pH test is the most accurate technique for ray, the pH test is the most accurate technique for checking tube placement. See checking tube placement. See Nursing Guidelines 29-1

30

31Figure 29-7 • Checking pH.

32

Once the nurse has confirmed stomach Once the nurse has confirmed stomach placement (using two methods is best), he or placement (using two methods is best), he or she secures the tube to avoid upward or she secures the tube to avoid upward or downward migration (downward migration (Fig. 29-8). ).

33

Figure 29-8 • (A ) One end of a piece of tape is split, forming two narrower strips, and the opposite end is left intact. (B ) The wider intact end of the tape is applied to the nose, and the narrower strips are wound around the tube in opposite directions to secure the nasogastric tube.

34

Use and Maintenance

Nasogastric tubes are connected to suction for Nasogastric tubes are connected to suction for gastric decompression or are used for tube gastric decompression or are used for tube feeding.feeding.

35

Gastric Decompression

Suction is either continuous or intermittent.Suction is either continuous or intermittent. The tube is connected to a wall outlet or The tube is connected to a wall outlet or

portable suction machine (Fig. 29-9). portable suction machine (Fig. 29-9).

36

Figure 29-9 • Suction removes liquids and gas from the stomach.

37

Promoting PatencyPromoting Patencywith intermittent suctioningwith intermittent suctioning

Giving ice chips or occasional sips of water to Giving ice chips or occasional sips of water to a client who is otherwise NPO promotes tube a client who is otherwise NPO promotes tube patency. The fluid helps to dilute the gastric patency. The fluid helps to dilute the gastric secretions. secretions.

38

Restoring PatencyRestoring Patency

The nurse assesses tube patency frequently by The nurse assesses tube patency frequently by monitoring the volume and characteristics of monitoring the volume and characteristics of drainage and observing for signs and drainage and observing for signs and symptoms suggesting an obstruction (nausea, symptoms suggesting an obstruction (nausea, vomiting, and abdominal distention).vomiting, and abdominal distention).

Sometimes the nasogastric tube must be Sometimes the nasogastric tube must be irrigated to maintain or restore patency (Skill irrigated to maintain or restore patency (Skill 29-2). 29-2).

39

RemovalRemoval

Nurses remove a nasogastric tube (Skill 29-3) Nurses remove a nasogastric tube (Skill 29-3) when the client's condition improves, when the when the client's condition improves, when the tube becomes hopelessly obstructed, or tube becomes hopelessly obstructed, or according to the agency's standards for according to the agency's standards for maintaining the integrity of the nasal mucosa.maintaining the integrity of the nasal mucosa.

40

Unobstructed larger-diameter tubes usually are Unobstructed larger-diameter tubes usually are removed and changed at least every 2 to 4 removed and changed at least every 2 to 4 weeks for adults. Small-diameter, flexible weeks for adults. Small-diameter, flexible tubes are removed and changed every 4 weeks tubes are removed and changed every 4 weeks to 3 months, depending on agency policy. to 3 months, depending on agency policy.

41

Transabdominal Tube Transabdominal Tube ManagementManagement

The physician inserts transabdominal tubes, The physician inserts transabdominal tubes, such as gastrostomy and jejunostomy tubes, such as gastrostomy and jejunostomy tubes, but the nurse is responsible for assessing and but the nurse is responsible for assessing and caring for them and their insertion sites. caring for them and their insertion sites. Conscientious care is necessary because Conscientious care is necessary because gastrostomy tubes may leak (Box 29-1) and gastrostomy tubes may leak (Box 29-1) and cause skin breakdown. See Nursing Guidelines cause skin breakdown. See Nursing Guidelines 29-3.29-3.

42Figure 29-12 • Inspection. (A ) Inspecting for drainage. (B ) Inspecting the skin.

43

Box 29-1 • Causes of Gastrostomy Leaks

Disconnection between the feeding delivery tube and G-tubeDisconnection between the feeding delivery tube and G-tube Clamped G-tube while tube feeding is infusingClamped G-tube while tube feeding is infusing Mismatch between the size of the G-tube and stomaMismatch between the size of the G-tube and stoma Increased abdominal pressure from formula accumulation, Increased abdominal pressure from formula accumulation,

retching, sneezing, coughingretching, sneezing, coughing Underinflation of the balloon beneath the skinUnderinflation of the balloon beneath the skin Less than optimal stoma or stomal locationLess than optimal stoma or stomal location

44

Providing nutrition by the oral route is always Providing nutrition by the oral route is always best. However, if oral feedings are impossible, best. However, if oral feedings are impossible, nourishment is provided enterally or nourishment is provided enterally or parenterally (see Total Parenteral Nutrition, parenterally (see Total Parenteral Nutrition, Chap. 16). Chap. 16).

Tube feedings are used when clients have an Tube feedings are used when clients have an intact stomach or intestinal function but are intact stomach or intestinal function but are unconscious, have undergone extensive mouth unconscious, have undergone extensive mouth surgery, have difficulty swallowing, or have surgery, have difficulty swallowing, or have esophageal or gastric disorders. esophageal or gastric disorders.

45

Benefits and RisksBenefits and Risks

For example,For example, dumping syndromedumping syndrome (cluster of (cluster of symptoms from the rapid deposition of calorie-dense symptoms from the rapid deposition of calorie-dense nourishment into the small intestine). The symptoms, nourishment into the small intestine). The symptoms, which include weakness, dizziness, sweating, and which include weakness, dizziness, sweating, and nausea, are caused by fluid shifts from the circulating nausea, are caused by fluid shifts from the circulating blood to the intestine and low blood glucose level. blood to the intestine and low blood glucose level. Diarrhea also may result when administering Diarrhea also may result when administering hypertonic formula solutions. hypertonic formula solutions.

46

Formula Considerations

In addition to the type of tube and the access In addition to the type of tube and the access site, the type of formula also is individualized, site, the type of formula also is individualized, based on the client's nutritional needs (Table based on the client's nutritional needs (Table 29-4). Factors include the client's weight, 29-4). Factors include the client's weight, nutritional status, and concurrent medical nutritional status, and concurrent medical conditions and the projected length of therapy. conditions and the projected length of therapy.

47

48

Tube-Feeding SchedulesTube-Feeding Schedules

Tube feedings may be administered on bolus, Tube feedings may be administered on bolus, intermittent, cyclic, or continuous schedules.intermittent, cyclic, or continuous schedules.

49

Bolus FeedingsBolus Feedings

A A bolus feedingbolus feeding (instillation of liquid (instillation of liquid nourishment in less than 30 minutes four to six nourishment in less than 30 minutes four to six times a day) usually involves 250 to 400 mL times a day) usually involves 250 to 400 mL of formula per administration.of formula per administration.

50

Intermittent FeedingsIntermittent Feedings

An An intermittent feedingintermittent feeding (gradual instillation (gradual instillation of liquid nourishment four to six times a day) of liquid nourishment four to six times a day) is administered over 30 to 60 minutes, the time is administered over 30 to 60 minutes, the time most people spend eating a meal. The usual most people spend eating a meal. The usual volume is 250 to 400 mL per administration. volume is 250 to 400 mL per administration.

51

Cyclic FeedingsCyclic Feedings

A A cyclic feedingcyclic feeding (continuous instillation of (continuous instillation of liquid nourishment for 8 to 12 hours) is liquid nourishment for 8 to 12 hours) is followed by a 16- to 12-hour pause. followed by a 16- to 12-hour pause.

52

Continuous FeedingsContinuous Feedings

A A continuous feedingcontinuous feeding (instillation of liquid (instillation of liquid nutrition without interruption) is administered nutrition without interruption) is administered at a rate of approximately 1.5 mL/minute. A at a rate of approximately 1.5 mL/minute. A feeding pump is used to regulate the feeding pump is used to regulate the instillation.instillation.

53

Client AssessmentClient Assessment

The following daily assessments are standard The following daily assessments are standard for almost every client who receives tube for almost every client who receives tube feedings: weight, fluid intake and output, feedings: weight, fluid intake and output, bowel sounds, lung sounds, temperature, bowel sounds, lung sounds, temperature, condition of the nasal and oral mucous condition of the nasal and oral mucous membranes, breathing pattern, gastric membranes, breathing pattern, gastric complaints, status of abdominal distention, complaints, status of abdominal distention, vomiting, bowel elimination patterns, and skin vomiting, bowel elimination patterns, and skin condition at the site of a transabdominal tube.condition at the site of a transabdominal tube.

54

Once tube feedings have been initiated, it is also Once tube feedings have been initiated, it is also necessary to routinely assess the client's necessary to routinely assess the client's gastric gastric residualresidual (volume of liquid within the stomach). The (volume of liquid within the stomach). The nurse measures gastric residual to determine whether nurse measures gastric residual to determine whether the rate or volume of feeding exceeds the client's the rate or volume of feeding exceeds the client's physiologic capacity. Overfilling the stomach can physiologic capacity. Overfilling the stomach can cause gastric reflux, regurgitation, vomiting, cause gastric reflux, regurgitation, vomiting, aspiration, and pneumonia. As a rule of thumb, the aspiration, and pneumonia. As a rule of thumb, the gastric residual should be no more than 100 mL or no gastric residual should be no more than 100 mL or no more than 20% of the previous hour's tube-feeding more than 20% of the previous hour's tube-feeding volume volume

55

Nursing ManagementNursing Management

Maintaining Tube PatencyMaintaining Tube Patency

To maintain patency, it is best to flush feeding tubes To maintain patency, it is best to flush feeding tubes with 30 to 60 mL of water immediately before and with 30 to 60 mL of water immediately before and after administering a feeding or medications, every 4 after administering a feeding or medications, every 4 hours if the client is being continuously fed, and after hours if the client is being continuously fed, and after

refeeding the gastric residualrefeeding the gastric residual..

56

Clearing an ObstructionClearing an Obstruction

Occasionally, it is possible to clear the tube with a Occasionally, it is possible to clear the tube with a solution solution

When an obstruction cannot be cleared, the When an obstruction cannot be cleared, the tube is removed and another inserted rather tube is removed and another inserted rather than compromising nutrition by the delay than compromising nutrition by the delay

57

Providing Adequate HydrationProviding Adequate Hydration

Although tube feedings are approximately 80% Although tube feedings are approximately 80% water, clients usually require additional hydration. water, clients usually require additional hydration. Adults require 30 mL of water per kilogram of body Adults require 30 mL of water per kilogram of body weight weight

58

Dealing With Miscellaneous ProblemsDealing With Miscellaneous Problems

Clients who require enteral feeding experience several Clients who require enteral feeding experience several common or potential problems. Many are associated common or potential problems. Many are associated with tube-feeding formulas or the mechanical effects with tube-feeding formulas or the mechanical effects

of the tubes themselves (Table 29-5 of the tubes themselves (Table 29-5 IMPORTANTIMPORTANT).).

59

60

61

62

Nursing ImplicationsNursing Implications

Imbalanced Nutrition: Less Than Body Imbalanced Nutrition: Less Than Body RequirementsRequirements

Self-Care Deficit: FeedingSelf-Care Deficit: Feeding Impaired SwallowingImpaired Swallowing Risk for AspirationRisk for Aspiration Impaired Oral Mucous MembranesImpaired Oral Mucous Membranes DiarrheaDiarrhea ConstipationConstipation