NRAD 201B

Nursing Process: Energy, Psychomotor

Nasogastric Tubes Enteral Feeding Administering Medications via NGT and PEG

Rationale for Nasogastric Tubes - 1

1. Gastric Emptying (Decompression)
Bowel obstruction GI Bleed After GI surgery Ileus (paralytic ileus)

2. Gastric Lavage Washing out: In & Out

Poisoning NS in/out to remove poison quickly Overdose same Gastric bleeding Iced NS can be used Critical Elements: Correct solution & temperature, Control rate/volume of introduction/return of fluid.

Rationale for Nasogastric Tubes - 2

3. Gastric Gavage gavage goes in
Pt. cannot eat/swallow safely but has a functioning GI Tract Instillation of liquid food Through an NGT or tube into stomach or jejunum Enteral feeding

Week 12 - Nasogastric tubes, Enteral feeding

NRAD 201B

Nasogastric Tubes double lumen

Salem Sump Tube Normal adult size: 14F to 18F 120cm long Air vent or pigtail open to air
Rationale to prevent adhering to stomach lining Anti-reflux valve usually attached

Uses: emptying (decompression), lavage, Occasionally Gavage (enteral feeding)

Emptying (Decompression)
Application of negative pressure to nasogastric tube via wall suction
May be continuous or intermittent 20-40 mm/Hg = low suction

Continuous: Increased risk of gastric mucosal irritation with continuous suction > 25 mm/Hg Equipment required:
Suction regulator wall style or portable Collection canister Connecting tubing.

Week 12 - Nasogastric tubes, Enteral feeding

NRAD 201B

Maintaining Suction: Assessment

Secure external part of NG tube to the nose: verify tape is secure Check drainage tube and suction gauge tubing every hour: is it working? Irrigate with 20mL H2O if necessary to maintain patency or per agency policy Maintain air vent: is it clear? stomach contents draining out? May need to instill air to clear Critical Elements: Assess/reassess placement, Verify correct suction level, Verify patency of NGT

Nursing Care: Assessment

Abdominal assessment suction must be off to auscultate bowel sounds Verify placement - at the beginning of every shift and before instilling anything. Monitor Intake and Output Note color and character at the initial assessment and during your shift Special attention to nasal and oral care

How to Verify Placement

Imperative for client safety! Verification by x-ray is the gold standard! Is required at the time of placement for any type feeding tubes. At the beginning of the shift and as needed: 1. Aspirate gastric contents - note color 2. Insufflation: rapid injection 20-30mL air while auscultating epigastric area. A gurgle or whoosh should be heard

Week 12 - Nasogastric tubes, Enteral feeding

NRAD 201B

Documentation - example
0730 NGT in place to low intermittent suction.
Placement verified. Draining green fluid. Abdomen soft, hypoactive bowel sounds noted. States has not passed gas but is feeling better. M. Bright SN 0930 Vomited 50mL dark brown fluid. NGT in place. Suction off. Placement verified. Abdomen round, tender, firm. Hypoactive bowel sounds. Placed to low intermittent suction with return 200mL dark brown fluid.. M. Bright SN

Nasogastric Tubes small bore feeding

Adult size: 8F to 12F Internal stylet and weighted end to facilitate insertion Designed for enteral feeding only.

Week 12 - Nasogastric tubes, Enteral feeding

NRAD 201B

Gastrostomy Tubes
Designed as long-term enteral feeding device Surgically or endoscopically placed in the stomach by a physician Larger in diameter than nasogastric feeding tubes PEG percutaneous endoscopic gastrostomy

Insertion Nasogastric tube

Critical elements: Insert, verify placement, secure exterior of tube Explain procedure to client Collect and set-up required equipment Position client: head of bed elevated as much as possible Measure and mark the tube: nose to ear, ear to stomach

Insertion Nasogastric tube

Chin up initially until past soft palate & down back of throat Chin down have pt swallow, may need a sip of water Push tube down smoothly and fairly quickly to mark Stop if resistance encountered Stop for extreme coughing Stop for compromised breathing Verify placement: aspiration, insufflation

Week 12 - Nasogastric tubes, Enteral feeding

NRAD 201B

Documentation - example
1030 #16F Salem sump inserted via right nare. Secured. Placement verified. Connected to low continuous suction with return 300mL tan fluid. Minimal distress on part of pt. M. Bright SN Small bore tube (stylette left in place until after Xray) 1100 #8F feeding tube inserted via left nare. Secured at 75cm. CXR (chest x-ray) ordered to verify placement. Unresponsive during procedure. M. Bright SN

Nursing Process
Imbalanced Nutrition: Less than Body Requirements A state in which a person who is not NPO experiences or is at risk of experiencing reduced weight related to inadequate intake or metabolism of nutrients for metabolic needs Defining characteristics: Food intake less RDA with or without weight loss and/or metabolic needs in excess of intake Risk for Aspiration State in which a person is at risk for entry of secretions, solids, fluids, into the tracheobronchial passages Deficient Fluid Volume A person who can take fluids (not NPO) experiences or is at risk of experiencing dehydration Insufficient oral fluid intake, negative balance I&O

Enteral Feeding
Indications: Nutrition Less than Body Requirements combined with inability to chew and swallow food normally. Methods: Continuous, intermittent, bolus Hazards and Complications: ASPIRATION, nausea,vomiting, diarrhea, abdominal cramping

Week 12 - Nasogastric tubes, Enteral feeding

NRAD 201B

Enteral Feeding
Review facility specific Policy & Procedure Review Physicians orders for: -feeding tube type -formula: type, strength, additional free water -feeding schedule -checking residuals and when to hold or resume feedings Check facility policy for: -when to change container, tubing -formula hang time

Nursing Care
Feed in semi-fowlers position and maintain position for 2 hours after feeding. How should the client be positioned if feeding is continuous? Check placement at beginning of shift and before feeding! Check for residual per physician orders or every 4 hrs. if continuous or before feeding if intermittent or bolus. Hold per Physician orders Aspirated residual is returned to the stomach Critical Thinking: how do you assess tolerance to feeding?

Critical Elements: Feeding per NGT

1. Assess/reassess for correct placement 2. Check residuals q 2-4 hrs and prn 3. Secures tube and monitor integrity of securing mechanism 4.Flush tube before/after medication administration 5. Skin care (pressure points where tube may be pressing): keep clean & dry

Week 12 - Nasogastric tubes, Enteral feeding

NRAD 201B

Medication Administration via NGT/PEG

Assessment - Is the medication appropriate to crush?? Medications must be in liquid form or crushed. Dissolve in warm H2O Verify placement of NG tube/PEG 1. Flush with H2O (20mL or *per policy) 2. Administer medication draw up in syringe 3. Flush with another 20mL * H2O, clamp for 30 before returning to suction (if suction ordered).

Removal of Nasogastric Tube

Review Physicians order Gather equipment and explain procedure Disconnect from suction tubing Position the client and remove tape securing tube Remove smoothly and quickly while client holds breath Assist client with nasal care Document!!

Documentation - examples
1100 Placement feeding tube verified. Abdomen soft, active bowel sounds noted. Head of bed up 45 degrees. Jevity strength, 50mL/hr started via feeding pump. M. Bright SN. 0800 Abdomen firm, active bowel sounds noted. PEG placement verified. 20mL residual noted. Full strength Glucerna @ 50mL/hr via feeding pump. Denies nausea, cramping. M. Bright SN

Week 12 - Nasogastric tubes, Enteral feeding