Practical Nursing Diploma Program - Semester II Labs

1. Practical Nursing Diploma Program - Semester II Labs N/G tube/J tube/G tube Feeding

3. Indications for enteral feedings [1305] • oral surgery • swallowing difficulties ( dysphagia) from dementias, CVAs, Parkinson’s,.. • Respiratory failure with prolonged intubation • GI disorders such as IBD, pancreatitis,…

4. delays wound healing, immune system deteriorates, lengthens hospital stays • enteral feedings provide more nutrition per volume, cause fewer infections and complications and costs less than parenteral feedings • one study showed that up to 1/2 of hospitalized patients may be malnourished

5. Types of tubes……. • may be short term or long term situation • short term feedings may be given through nasogastric tube or nasointestinal tube • long term given through gastrostomy or jejunostomy tube • G and J tubes may require surgical procedures and general anesthetic

7. percutaneous endoscopic gastrostomy tubes are becoming more popular as can be inserted at the bedside using local anesthetic and an endoscope • another option is the LPGD or low profile gastrostomy device - better for long term, continuous feedings in active adults, children

10. French size refers to the outer diameter of the tube with larger tubes having higher French size (same as foley catheters, suction tubes etc.) • most made of silicone and/or polyurethane • use of gastrostomy tube requires a functioning GI tract • J tubes are an alternative if there are problems with the GI tract

11. these tubes are relatively stable and difficult to dislodge but require special care to avoid skin breakdown etc. • tape tube to abdomen to prevent movement

12. Feeding Schedule • based on pt’s physical, medical and nutritional condition • continuous feedings - gradual introduction of formula into GI tract allowing for maximal absorption - requires use of feeding pump which limits movement

13. continuous feeding into intestine (J tube) used to avoid dumping syndrome • continuous feeding into stomach (G tube) is controversial due to risk of reflux and aspiration

14. Intermittent or Cyclic Feedings • intermittent feedings are given over specific period of time at regular intervals ie. q6h and run over 3 hours • cyclic feeding involves giving continuous feeding over a specific time frame (usually 12-16 hours overnight) in a 24 hour period which allows the patient to eat normally during the day and allows for more mobility

15. Feeding Formulas • component of feed depends on the route, the patient’s ability to digest and absorb nutrients and his/her nutrient and fluid requirements • also have to consider medical conditions that require special diets, food intolerances, and allergies

16. typical formula contains : 16% protein, 54% carbohydrate and 30% fat • most contain 1 calorie per mL but some contain more so check it out • dietician is generally involved in this process to ensure patient gets proper formulation depending on individual need

17. Potter & Perry [1311-1317] • may be prefilled bottles that you simply spike and hang or bags/containers that you have to fill • lots of different products on the market so know what your patient’s needs are and question if order inappropriate • Given via feeding pump or gravity

18. Use of feeding pumps…….. • Usually have specialized tubing specific to the individual pump • regulates rate of feeding delivered to patient • allows increased control and accuracy • most have built in safe guards (alarms) to prevent free flow, attachment to IV tubing (different sized tip), automatic tube flush • audible and visual alarms • most operate up to 8 hours on battery but should be plugged in whenever possible

19. Confirming placement of tube…. • J and G tubes require regular assessment to determine that they have not become dislodged • this involves measuring the length of the tube outside of the body and comparing to length at time of insertion • NG tubes increase risk of aspiration and must be checked prior to each use to ensure correct placement ie. Not in lungs!!!

20. GI Aspirate [1319] • another method used primarily with NG tubes is to check the pH of the aspirate • wait about 1 hour post medication or feeding or stop continuous feeding for one hour • insert 30 mL of air into tube and aspirate 5-10 mL of gastric secretions

21. place drop of secretion on pH paper and compare colour with chart from manufacturer • stomach pH = 0-4, or 4-6 if taking acid inhibiting agent • Intestinal pH = 7 or higher • respiratory tract pH = 6 or higher

22. colour of aspirate is also a clue as to its origin • stomach - green, tan, off white, bloody or brown • intestine - medium to deep golden yellow - may be greenish brown if stained with bile • resp tract - off white and tinged with mucous

23. Safety Checks for any Delivery Method • always check tube from beginning to end to ensure intact and attached to right machine and container • check tube for placement prior to each feed • check residual, according to policy, before each feeding or every 4-6 hours if continuous and report excess of over 100 mL • assess bowel sounds at least once per shift

24. Prevent contamination during feeding by: • washing hands prior to handling any part of system • using closed system when possible • checking expiry date of formula • follow policy for the type of fluid for flushing tube • cap disconnected tubes properly

25. replace setup every 24 hours or wash reusable setup with soap and hot water every 24 hours (check organization’s policy for these activities) • label container with pt’s name, date and time feeding hung

26. Administering an enteral feeding • explain procedure • check bowel sounds • gather equipment • check amount, concentration, type, expiry date and frequency of tube feeding with chart • wash hands, put on gloves

27. position patient with HOB elevated about 30 degrees • examine tube for proper placement • check pH and residual if indicated [1319] • prepare formula and clear tubing of air • For gravity feed, hang feeding on IV pole about 12 inches above stomach

28. attach tube to patient tubing and regulate rate manually or with pump • flush tubing post feed with 30-60 mL of fluid type according to agency policy • observe patient response during and after • have patient remain upright for 30-60 mins after intermittent feed • wash and clean equipment or discard depending on equipment used

29. document type and amount of feeding and patient’s response • monitor blood glucose if required

30. Complications • extubation - measure tube at regular intervals, anchor tube securely, check patency at least q shift • stoma complications - clean site q shift with soap and water and dry thoroughly, assess for signs of infection • provide exceptional mouth care to prevent drying and relieve thirst

31. clogged tube - flush q4h during continuous feed and at start and end of intermittent and after withdrawing aspirate - use 30 mL of water with a 50 mL syringe • diarrhea - start feed slowly, prevent contamination, assess for fecal impaction • N & V - check residual q4h if continuous and at start of intermittent feed

32. if your patient complains of abdominal pain, bloating or N&V, stop the feeding, reassess the patient and resume at a slower rate

33. Administering medication through a feeding tube……. • safety measures – 3 checks and 6 rights • use liquid form or meds that can be crushed and combined with liquid • have med at room temperature • ensure proper tube placement prior to administering medication

34. flush tube with 15 – 30 ml of water before and after giving med to check patency and prevent plugging of tube • give each med separately and flush after each one • don’t forget to count “flush” in I & O • many meds can’t be given together due to interactions so check first

35. if tube connected to suction, disconnect and allow 20 – 30 minutes for absorption of med before reconnecting • disconnect continuous feeding prior to giving meds and leave off according to agency policy • document