Chapter 29 Gastrointestinal Intubation

1. Chapter 29 Gastrointestinal Intubation

2. Intubation Intubation: placement of a tube into a body structure Types of intubation Orogastric: mouth to stomach Nasogastric: nose to stomach Nasointestinal: nose to intestine Ostomy: surgically created opening

3. Question Is the following statement true or false? Orogastric intubation is the insertion of a tube through the nose into the stomach.

4. Answer False. Orogastric intubation is the insertion of a tube through the mouth into the stomach.

5. Intubation (cont’d) Gastric or intestinal tube uses include: Performing Gavage (Giving nourishment, i.e. liquid food) Administering oral medications Sampling sections for diagnostics Performing a Lavage (contents Leaving the stomach or withdrawing, i.e. poisons) Compression or tamponade (controlling gastric bleed) Decompression (removing gas & liquid from stomach/bowel over an extended period of time)

6. Types of Tubes All tubes are measured using the French scale indicated by a number (outside diameter) followed by the letter “F” (i.e. 20F) Gastrointestinal tubes (Fig 29-1; Pg. 666) Orogastric tubes Nasogastric tubes (Levin, Salem-sump, Blakemore) Feeding, decompression One or two lumens available: salem sump tubes have double-lumens (lumen = opening/channel)

7. Types of Tubes (cont’d) Nasointestinal tubes (Keofeed) Longer & smaller diameter than nasogastric tubes Made of softer material (like silicone) = more comfortable for patients Feeding, decompression Transabdominal tubes (ostomy) Gastrostomy tube (through the abdomen and into the stomach) Jejunostomy tube (through the abdomen and into the jejunum)

8. Question Is the following statement true or false? A nasointestinal tube is a tube placed through the nose and advanced to the stomach.

9. Answer False. A nasointestinal tube is inserted through the nose for distal placement below the stomach.

10. Types of Gastrointestinal Tubes

11. Nasogastric Tube Management Pre-Intubation assessments: Level of consciousness; weight Bowel sounds; abdominal distention Nasal/oral mucosa integrity – nasal inspection Swallow, cough, gag ability Nausea or vomiting present?

12. Question Is the following statement true or false? Assessing abdominal distention is part of preintubation assessment conducted by the nurse.

13. Answer True. Assessing abdominal distention is part of preintubation assessment conducted by the nurse.

14. Tube Measurement and Placement NEX measurement (Fig 29-5; pg. 668) Length from Nose to Earlobe to Xiphoid process, marking tubing for reference point Insertion should cause as little discomfort as possible Determine proper placement using: Auscultation – listening for air “swoosh” or gurgling sound Aspiration – visual inspection of stomach contents; pH testing (diagnostic) Xray (initially & when suspect complications)

15. Assessing the pH of Aspirated Fluid

16. Nasogastric Tube Management Gastric decompression Suction continuously or intermittently Vented tubing protects stomach mucosa Promote/restore patency Administer ice chips or sips of water sparingly Irrigation (by physician order only)

17. Inserting a Nasogastric Tube (Refer to Skill 29-1 in the textbook.)

18. Nasointestinal Tube Management Insertion of nasointestinal tubes NEX measurement + 9 inches Checking tube placement Initially via x-ray Subsequently, modified aspiration with large volume syringe (50 mL)

19. Transabdominal Tube Management Although nurses do not insert tubes transabdominally, the nurse’s responsibility is to care for inserted gastrostomy and jejunostomy tubes and their insertion sites Conscientious care is necessary to prevent leakage and skin breakdown

20. Care of Nasogastric Tube Students: Review skill 29-2; 29-3 & 29-4 in the textbook You will complete this in Skills Lab!

21. Comparison of Feeding Tubes

22. Tube Feedings Enteral nutrition is provided via stomach or small intestine (nasogastric, nasointestinal, & transabdominal) rather than oral route Benefits and risks Dumping syndrome Formula type based on client’s nutritional needs

23. Question Which of the following are symptoms of the dumping syndrome? Select all that apply. a. Sweating b. Appetite loss c. Weakness d. Nausea

24. Answer a. Sweating, c. Weakness, d. Nausea The symptoms of dumping syndrome are weakness, dizziness, sweating, and nausea, due to fluid shifts from the circulating blood to the intestine, and low blood glucose level related to a surge of insulin. Appetite loss is not a symptom of the dumping syndrome.

25. Tube Feedings (cont’d) Tube-feeding schedules Bolus feedings: usually 250-400 ml; least desirable method Intermittent feedings: gradual instillation 4-6 times/day that is administered over a 30-60 minute timeframe; the stomach is filled & emptied = more like a meal schedule Cyclic feedings: continuous (8-12 hours) instillation followed by a 12-16 hour pause in feeding; given during late evenings & encourages patients to eat during the day Continuous feedings: instillation of small amts without interruption; use feeding pump; best for unconscious pt; small amounts reduce the risk for aspiration

26. Tube Feedings (cont’d) Daily client assessment: weight, vital signs, intake/output, bowel sounds, lung sounds, breathing, mucosal condition, etc. Regular gastric residual assessment Should be no more than 100 ml Review residual guidelines on pg. 675 Nursing management Maintain tube patency (w/ 30-60 ml water flushes); clear obstructions; provide adequate hydration; ready client for home care; address miscellaneous problems Common tube feeding problems, pg. 677

27. Checking Gastric Residual

28. Clearing an Obstructed Feeding Tube

29. Intestinal Decompression Intestinal decompression: tubing introduced into the intestines to decompress in an attempt to avoid surgery Nursing responsibilities may include: Tube insertion Removal of intestinal decompression tube Performed slowly, in two steps at 10-minute intervals

30. Inserting an Intestinal Decompression Tube

31. Risk for Aspiration Review Nursing Care Plan 29-1 pg. 679

32. Nursing Implications Potential nursing diagnoses: Impaired swallowing and oral mucous membranes Imbalanced nutrition: less than body requirements Risk for aspiration Diarrhea Constipation

33. General Gerontologic Considerations Diminished efficiency of the gag reflex Precautions when tube feeding older adults related to hyperglycemia and hydration Tailor formula specifically to client condition Monitor older adults for agitation, confusion resulting in pulling tubes; change in mental status can signal electrolyte imbalance

34. Question Is the following statement true or false? Older adults may develop hyperglycemia when tube feedings are administered.

35. Answer True. Older adults are at increased risk for fluid and electrolyte disturbances and, as a result, may develop hyperglycemia (elevated blood glucose levels) when tube feedings are administered.

36. General Gerontologic Considerations When instructing older adults or older caregivers in managing gastrostomy tube or administering tube feedings at home, allow more time for processing and include several practice sessions Ethical considerations of long-term tube feedings vs. client’s desire to withdraw artificial nutrition and hydration

37. End of chapter NCLEX review