Fundamental of nursing

1. King Saud University College of Nursing Fundamental of nursing Module 6 • Nutritional management • Nutrient via tube feeding

3. GI Therapy • The GIT digests ingested foods and transports nutrients across its mucosa into the bloodstream. • Physical and mechanical processes of digestion begin in the mouth, …………. • The average mealremains for 3 hrs in the stomach, • Enzymes & Hormones • The role GIT is to dilute, digest, transport, and absorb nutrients and secretions. Essential body nutrients CHO, Fats, Protein, Vit, minerals, water.

4. Factors affecting nutrition: Food habits are a product of many evolving variables such as: Physical factors: geographic location, food technology, income. Physiologic factors: health, hunger, stage of development. Psychosocial: culture, religion, tradition, education, politics, social status, food ideology,

5. Gastrointestinal Tube therapy Rationale: • To provide a means for GI decompression for obstructive disease or surgical wound healing. • To providea means for temporary postoperative decompression until normal GI motility is restored. • To obtain gastric content samples for analysis (PH, etc). • To lavage the stomach to remove blood or toxic ingested substances. • To monitor the quantity of GT bleeding. Assessment: • Verify that Dr. has written orders for type & purpose of tube to be inserted. • Verify that order specifies suction or gravity drainage for decompression

6. Assessment cont’d: • Monitor client’s VS , intake and output (I&O), and relevant lab data e.g. electrolytes. • Monitor ongoing IV fluid replacement therapy. • Utilize a variety of validation technique to determine that tube is patent and in desired position. • Monitor quantity and character of aspirated secretion. • Assess that tube remains patent by regular flashing. • Assess client’s abdomen( e.g. not distended, soft, bowel sounds,…etc) and subjective complaints. • Monitor client’s elimination pattern and character of stool.

7. Large – bore NGT insertion: Equipment • NGT e.g. Levin, Salem) • Irrigation syringe(50ml) with catheter tip • Water- soluble lubricant • Towel • Tissue • Emesis basin • Stethoscope • Glass of water • Clean gloves • Penlight or flashlight • Tape

8. Large – bore NGT insertion: Procedure: • Elevate head of bed to 45 degree angle. To promote safety during tube insertion. • Place towel over client’s chest and emesis basin within reach. • Inspect client’s nose to select naris that has better airflow; ask client about deviated septum and previous injury or surgery, and check ability to breathe through both nares by occluding one at a time. • To determine length of tube to be inserted, use tube to measure from the tip of client’s nose to earlobe

9. Large – bore NGT insertion: Procedure cont’d: • To this measurement, add length from earlobe to xiphoid process of sternum plus 6 in. mark determined distance on tube with tape or pen. • Coil end of tube over your fingers. (Soften tube and facilitates insertion). • Lubricant the first 3-4 in of tube with Water- soluble lubricant . • With client’s head upright or slightly extended, carefully inserted tube into client’s nostril, aim it toward client’s ear and downward , and gently advance it toward client’s nasopharynx. Rationale: turning and directing tube help it confirm to anatomic passageway . When tube reach nasopharynx, resistance will be felt.

10. Large – bore NGT insertion: Procedure cont’d: • Have client open mouth and check with penlight to visualize tube. RATIONALE: To verify that tube is at back of throat and not coiled up in mouth . • Once tube is advanced toward back of the throat, have client flex head forward, then rotate tube 180 degree inward toward client’s other nostril. This helps direct tube past nasopharynx. • Ask client to dry swallow or sip water several times while advancing tube until tape mark is reached. If client gags, briefly stop tube advancement. (swallowing opens upper esophageal sphincter and allows tube enter esophagus. • Aspirate 20-30ml of air into syringe; attach syringe to free end of NGT to check for tube position. Tube must be in elementary canal not in respiratory tract.

11. Large – bore NGT insertion: Procedure cont’d: • Place stethoscope over client’s epigastric region, then inject air and listen for swooshing sound. this indicates that tube probably reach stomach. • Keeping syringe attached, pull back on plunger to aspirate gastric contents; check for color and PH of the contents. • Use pen to mark tube near client’s naris for future monitoring of tube placement and possible migration. • Make “pair of pants” of tape by using 2-3 in piece of tape and splitting it half- way up the middle.

12. Large – bore NGT insertion: Procedure cont’d: • Place body part of pants tape on client's nose. • Wrap tape legs around NGT, to stabilize tube. • Loop piece of tape or rubber band around tube to pin it to client’s gown. • Pin tube or rubber band to client’s gown to secure tube above client’s stomach. • Plug end of tube, or connect end of tube intermittent\ continuous suction device for decompression.

13. NGT Irrigation Equipment: • Towel • Stethoscope • 50 ml irrigation syringe • Sterile Normal saline( NS) • Clean gloves Procedure: • Place towel underneath tube to protect bed linens. Disconnect tube from suction. Determine tube placement by auscultation and aspiration of secretions . • Draw up 20-30 ml of normal saline solution. • Gently instill NS into NGT or remove syringe plunger, pour NS solution into barrel, and allow solution to flow in by gravity. • Reconnect tube suction, or reclamp tube if suction is not used. Record in the I&O chart.

14. Small – bore NGT feeding: Rationale: • To provide a means for intermittent nutritional feeding into the stomach. • To provide a means for continuous nutritional feeding into the small intestine. • To provide a means for medication administration. Assessment: • Verify that Dr. has written an order for type of NGT to be inserted. • Verify that order specifies desired placement on tube ( e.g. gastric, intestinal). • Verify that Dr’s order specifies type, amount, and frequency of enteral feeding. • Validate client’s identity; check room number and identaband and have client state name. • Ausculate to ensure client has bowel sounds.

15. Small – bore NGT feeding: Assessment cont’d: • Assess that client’s nasal passage is patent to allow tube insertion. • Determine if client is able to swallow to assist in tube advancement. • Verify that tube is placed in desired location by using several validation techniques. Equipment: • NGT • Water- soluble lubricant • Towel • Tissue • Emesis basin • Stethoscope • Glass of water with straw • clean gloves • Penlight or flashlight • Tape • NS solution • Syringe 60 ml • pen

16. Small – bore NGT feeding: Procedure: • To determine length of tube to be inserted, use tube to measure from the tip of client’s nose to earlobe, then to xiphoid process, then adding 10 in. Small bowel placement requires at least 40 in of tubing . This additional measurement allows tube to migrate into small intestine . • Lubricant the first 3-4 in of tube with Water- soluble lubricant. • With client’s head upright or slightly extended, carefully inserted tube into client’s nostril, aim it toward client’s ear and downward , and gently advance it toward client’s nasopharynx. Rationale: turning and directing tube help it confirm to anatomic passageway . When tube reach nasopharynx, resistance will be felt.

17. Small – bore NGT feeding: Procedure cont’d: • Have client open mouth and check with penlight to visualize tube. RATIONALE: To verify that tube is at back of throat and not coiled up in mouth . • Once tube is advanced toward back of the throat, have client flex head forward, then rotate tube 180 degree inward toward client’s other nostril. This helps direct tube past nasopharynx. • Ask client to dry swallow or sip water several times while advancing tube until tape mark is reached. If client gags, briefly stop tube advancement. (swallowing opens upper esophageal sphincter and allows tube enter esophagus. • Aspirate 20-30ml of air into syringe; attach syringe to free end of NGT to check for tube position. Tube must be in elementary canal not in respiratory tract.

18. Small – bore NGT feeding: Procedure cont’d: • Place body part of pants tape on client's nose. • Wrap tape legs around NGT, to stabilize tube. • Loop piece of tape or rubber band around tube to pin it to client’s gown. • Pin tube or rubber band to client’s gown to secure tube above client’s stomach.

19. Intermittent Large– bore NGT feeding: Equipment: • Prescribed nutritional formula • Calibrated container for measuring formula • Irrigation syringe 50 ml • Calibrated container of water for flushing . • Clean gloves Preparation: • Date and refrigerate open formula can. • Warm refrigerate formula to room temp. (in hot water) • Elevate head of bed to a 30 degree angle or higher. • Assess that NG or gastrostomy tube has not migrated

20. Intermittent Large– bore NGT feeding: Procedure : • Ausculate to ensure client has bowel sounds. • Determine position of NGT using sounds with stethoscope, aspiration of gastric contents. • Aspirate gastric contents to determine residual volume. ( more than one-half of previously delivered, hold feeding and recheck in 1hr • Return aspirated contents to stomach. Because its contain electrolytes; their return helps prevent electrolytes imbalance. • Remove plunger from syringe and attach empty syringe barrel to NGT.

21. Intermittent Large– bore NGT feeding: Procedure cont’d : • Holding syringe no longer than 18 in above client’s stomach, administer 30 ml water to flush and test tubing; clamp tubing by folding before syringe empties. • Pour feeding product into syringe barrel and allow to flow slowly by gravity over 15 min, forced delivery increase risk of cramping, nausea, or vomiting. • Clamp tubing before syringe empties or continuously fill syringe before it completely empties. • Flush tubing with 30 ml water and clamp.