gi procedures

Common types of tubes used in the clinical setting

Assessment points related to the specific type of tube

Procedures for insertion of a particular tube Standard (universal) precautions Handling infectious materials

Verifying correct placement and procedures for administering medications or feedings, if appropriate

Interventions related to the care of the client

Interventions associated with complications or emergencies that may occur

Client/family education regarding care at home

DESCRIPTION◦ Short tubes used to intubate the stomach◦ Inserted from the nose to the stomach

LEVINE◦ Single-lumen nasogastric tube◦ Used to remove gastric contents via intermittent

suction or to provide tube feedings

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.

SALEM SUMP◦ Double-lumen nasogastric tube with an air vent ◦ Used for decompression with continuous suction◦ Air vent is not to be clamped and is to be kept

above the level of the stomach◦ If leakage occurs through the air vent, instill 30 ml

of air into the air vent and irrigate the main lumen with normal saline (NS)

Place the client in high-Fowler’s position Measure from tip of nose to earlobe to

xiphoid process to determine the length of insertion and mark with tape

Lubricate tube about 3 inches with a water-soluble jelly only (oil-soluble is not used), to prevent the development of pneumonia if the tube accidentally slips into the bronchus

Instruct the client to bend the head forward, which closes the epiglottis and opens the esophagus

Insert into nostril, advance backward and through the nasopharynx

Have the client take a sip of water and advance tube as the client swallows

Do not force the tube If the client experiences any respiratory

distress (coughing or choking) during insertion, pull back on the tube and wait until the distress subsides

Advance until taped mark is reached; tape in place when correct placement is confirmed

If feedings are prescribed, x-ray confirmation should be done prior to initiating feedings

When gastrointestinal (GI) tubes are attached to suction, suction may be continuous or intermittent, with a pressure not exceeding 25 mmHg as prescribed by the physician

From Perry, A. & Potter, P. (2002). Clinical nursing skills and techniques, ed 5, St Louis: Mosby.

The most reliable method to determine placement is by x-ray

Assess placement every 4 hours and before administering feedings or medications

Assess placement by aspirating gastric contents and measuring the pH, which should be 4 or less (pH values greater than 6 indicate intestinal placement)

Inserting 5 to 10 ml of air into the NG tube and listening for the rush of air over the stomach with a stethoscope is an alternative method for assessing placement, but is not as reliable as an x-ray or checking gastric pH

Check residual volumes every 4 hours, before each feeding, and before giving medications

Aspirate all stomach contents (residual) and measure amount

Reinstill residual feeding to prevent excessive fluid and electrolyte losses unless the residual volume appears abnormal

Performed every 4 hours to check the patency of the tube

Assess placement before irrigating Gently instill 30 to 50 ml of water or normal

saline (NS) (depending on agency policy) with an irrigation syringe

Pull back on the syringe plunger to withdraw the fluid to check patency; repeat if tube remains sluggish

Ask the client to take a deep breath and hold

Remove the tube slowly and evenly over the course of 3 to 6 seconds (coil the tube around the hand as it is being removed)

TUBES◦ Nasogastric◦ Nasoduodenal or nasojejunal◦ Gastrostomy◦ Jejunostomy

TYPES OF FEEDINGS◦ Bolus◦ Continuous◦ Cyclical

BOLUS ◦ Resembles normal meal feeding patterns◦ Can be administered via a syringe or via an

intermittent feeding◦ With an intermittent feeding, approximately 300

to 400 ml of formula is administered over a 30- to 60-minute period every 3 to 6 hours

CONTINUOUS◦ Administered continuously for 24 hours◦ An infusion pump regulates the flow

CYCLICAL◦ Administered either in the daytime or nighttime

for 8 to 16 hours◦ An infusion pump regulates the flow◦ Feedings at night allow for more freedom during

the day

Position the client in high-Fowler’s and on the right side if comatose

Warm feeding to room temperature to prevent diarrhea and cramps

Aspirate all stomach contents (residual), measure the amount, and return the contents to the stomach to prevent electrolyte imbalances

Check physician’s order and agency policy regarding residual amounts; usually if the residual is less than 100 to 150 ml, feeding is administered; if greater than 150 ml, hold the feeding

Assess tube placement by aspirating gastric contents and measuring the pH (should be 4 or less)

Assess bowel sounds; hold feeding and notify the physician if bowel sounds are absent

Use a feeding pump for continuous or cyclical feedings

For bolus feeding, leave the client in a high-Fowler’s position for 30 minutes after feeding

For a continuous or cyclical feedings, keep the client in a semi-Fowler’s position at all times

Change the feeding container and tubing every 24 hours

Do not hang more solution than will be required for a 4-hour period to prevent bacterial growth

Check the expiration date on the formula prior to administering

Shake the formula well prior to inserting into container

Always assess placement of the tube prior to feeding

Always assess bowel sounds; do not administer any feedings if bowel sounds are absent

If an obstruction occurs, try flushing with water, saline, cranberry juice, ginger ale, or cola, if not contraindicated, after checking placement

Add a drop of methyline blue to the feeding, particularly with clients who have endotracheal or tracheal tubes; suspect tracheoesophageal fistula when blue gastric contents appear in tracheal excretion and if this is noted, notify the physician immediately

Administer feeding at prescribed rate, or via gravity flow (intermittent, bolus feedings) with a 60-ml syringe with the plunger removed

Gently flush with 30 to 50 ml of water or normal saline (depending on agency policy) with the irrigation syringe after the feeding

Aspiration Vomiting Diarrhea Clogged tube

Verify tube placement Do not administer feeding if residual is

greater than 150 ml Keep the head of the bed elevated If aspiration occurs, suction as needed,

assess respiratory rate, auscultate lung sounds, monitor temperature for aspiration pneumonia, and prepare to obtain chest radiograph

Administer feedings slowly, and for bolus feedings, make the feeding last for 30 minutes

Do not allow feeding to run dry Do not allow air to enter the tubing Administer feeding at room temperature Elevate the head of the bed Administer antiemetics as prescribed If client vomits, place in side-lying position

Use fiber-containing feedings Administer feeding slowly and at room

temperature

Use liquid forms of medication, if possible Flush the tube with 30 to 50 ml of water or

NS (depending on agency policy) before and after medication administration and before and after bolus feeding

Flush with water every 4 hours for continuous feeding

Crush medications or use elixir forms of medications; assure that the medication ordered can be crushed or that the capsule can be opened

Dissolve crushed medication or capsule contents in 5 to 10 ml of water

Check placement and residual prior to instilling medications

Draw up the medication into a catheter tip syringe, clear excess air, and insert medication into the tube

Flush with 30 to 50 ml of water or NS (depending on agency policy)

Clamp the tube for 30 to 60 minutes (depending on medication and agency policy)

DESCRIPTION◦ Passed nasally into the small intestine◦ Used to decompress the bowel or to remove

intestinal contents◦ Enters the small intestine through the pyloric

sphincter because of the weight of a small bag of mercury at the end

Cantor and Harris tube Miller-Abbott tube

Single-lumen tube with a reservoir for 5 to 10 ml of mercury located at its tip, below the level of the drainage holes

Mercury is inserted before the tube is passed through the nose, making the procedure uncomfortable

The Harris tube is also used for lavage and suction

A double-lumen tube One lumen is for the instillation of mercury

once the tube is in the stomach, and the other is for irrigation or drainage

From Monahan, F. & Neighbors, M. (1998) Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.

IMPLEMENTATION◦ Assess physician’s orders and agency policy for

advancement and removal of tube◦ Position client on the right side to facilitate

passage of the mercury weights within the tube through the pylorus of the stomach and into the small intestine

◦ Do not secure the tube to the face with tape until it has reached final placement (may take several hours) in the intestines

◦ X-ray is performed to verify desired placement

IMPLEMENTATION◦ Monitor drainage from the tube◦ If the tube becomes blocked, notify the physician;

a small amount of air injected into the lumen may be prescribed to clear the tube

◦ Assess the abdomen and measure abdominal girth

IMPLEMENTATION◦ To remove the tube, the mercury and air are

removed from the balloon portion of the tube with a 5-ml syringe; the tube is gradually removed (6 inches every hour) as prescribed by the physician

◦ Dispose the mercury in the appropriate manner as per agency policy

DESCRIPTION◦ Used to apply pressure against esophageal veins

to control bleeding◦ Not used if the client has ulceration or necrosis of

the esophagus or had previous esophageal surgery

TYPES◦ Sengstaken-Blakemore tube◦ Minnesota tube

Triple-lumen gastric tube with an inflatable esophageal balloon, an inflatable gastric balloon, and a gastric aspiration lumen

The gastric balloon applies pressure at the cardioesophageal junction to directly compress gastric varices and to decrease blood flow to esophageal varices; traction is applied to maintain the gastric balloon in place

The esophageal balloon directly compresses esophageal varices

If bleeding is not stopped with inflation of the gastric balloon, the esophageal balloon is inflated to 25 to 45 mmHg

An x-ray of upper abdomen and chest confirms placement

Gastric contents are aspirated by gastric lavage or intermittent suction via the gastric aspiration port

A nasogastric tube is also inserted in the opposite naris to collect secretions that accumulate above the esophageal balloon

From Monahan, F. & Neighbors, M. (1998), Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.

Four-lumen gastric tube A modified Sengstaken-Blakemore tube with

an additional lumen for aspirating esophagopharyngeal secretions

IMPLEMENTATION◦ Check patency and integrity of all balloons prior

to insertion◦ Label each lumen◦ Place the client in the upright or Fowler’s position

for insertion◦ Prepare for x-ray immediately after insertion to

verify placement◦ Maintain head elevation once the tube is in place

IMPLEMENTATION◦ Double-clamp the balloon ports to prevent air

leaks◦ Keep scissors at the bedside at all times; monitor

for respiratory distress and if it occurs, cut tubes to deflate balloons

◦ Release esophageal pressure as prescribed and per agency policy to prevent ulceration or necrosis of the esophagus

IMPLEMENTATION◦ Monitor for increased bloody drainage, which may

indicate persistent bleeding ◦ Monitor for signs of esophageal rupture, which

includes a drop in blood pressure, increased heart rate, or back and upper abdominal pain

◦ Esophageal rupture is an emergency and must be reported to the physician immediately

DESCRIPTION◦ Used to remove toxic substances from the

stomach

LAVACUATOR ◦ An orogastric tube with a large suction lumen and

a smaller lavage/vent lumen that provides continuous suction

◦ Irrigation solution enters the lavage lumen while stomach contents are removed through the suction lumen

EWALD’S◦ Reusable single-lumen large tube used for rapid

one-time irrigation and evacuation

gi procedures

Documents

advance tube

clinical nursing skills

stomach contents residual

tube accidentall slips

clinical practice

intermittent feeding

client interventions

correct placement