113_EnteralTube.1.8.2014._IFN.ICP.pdf

Management of

Central Venous Access Devices

Management of Patients with

Enteral Tubes

e-Module Management of Patients on Enteral Tubes

2

Purpose

This module is not intended to be all inclusive, but rather provides an overview of salient points related to management and care of patients with enteral tubes.

The purpose of this e-learning module is to educate Healthcare professionals on the Care of

a patient with Enteral Tubes.


3

Objectives

The learner will :

• Identify 3 different types of enteral tubes.

• Discuss healthcare providers responsibilities during insertion and management of nasogastric tube.

• Discuss healthcare providers responsibilities when using nasoenteric tubes for feeding and administering medication.

• Discuss Healthcare providers responsibilities for discontinuing nasoenteric tubes.


4

What is an Enteral Tube?

A device used to provide nutrition to patients who

cannot obtain nutrition by swallowing


5

Quick overview:

• Watch this 2 minute video overview on feeding tubes:

http://www.youtube.com/watch?v=iGMqtcBvN8Q&feature=related




6

• Lavage – Removal of blood or toxic waste

• Aspiration – Gastric content for samples Disease

• Malnutrition

• Risk for aspiration

• Administration of drugs *

• Critical injury or trauma

• Gastric decompression

*Pt must have a functioning GI tract to receive enteral nutrition

R

E

A

S

O

N

S

• Rest & heal GI tract

• Ileus

• Gastric atony

• Obstruction

• Correct fluid & electrolyte imbalance

• Alleviate Nausea, Vomiting

• Infection

• Psychiatric

Reasons for an enteral tube:


7

TYPES OF ENTERAL TUBES


8

NASOGASTRIC TUBE PLACEMENT


9

Large Bore Tubes

NET (nasoenteric tube) :

Inserted nasogastric (NG) or

nasointestinal (NI)

–Levin, Andersen, Salem Sump; size 8-18 French

–NG = 30 – 36 inches length

–NI = 43 – 60 inches length

•Introduced from the nose to the stomach

•Used to remove gas and fluid from the upper GI tract or to obtain a specimen of gastric contents

•Sometimes used for meds or feedings


10

• Used short term

• More irritating to esophageal mucosa and risk for aspiration

• Use < 30 days

Large Bore Tubes


11

Levin Tube

• Single Lumen (hollow part of tube)

• Made of plastic or rubber

• Circular markings on the tube serve as insertion guides

• Connected to low intermittent suction (20 to 80 mm Hg)


12

Gastric (Salem) Sump

• Double lumen catheter

• Used to decompress the stomach, keeps it empty

• BLUE PIGTAIL allows atmospheric air to enter the patient’s stomach so that the tube can float freely, thus preventing NGtube from adhering to and damaging the gastric mucosa.

– The LARGE PORT is the main suction/aspiration tube.


13

Sump cont.

• Connects to low continuous suction.

• Vent lumen kept above the client’s waist.

• Anti-reflux valve- prevents the reflux of gastric contents out of the vent lumen.

• After suction lumen is irrigated, air is injected. Reestablishes a buffer of air between the gastric contents and the valve.


14

Small Bore tubes

• Used longer term

> 30 days

• Less irritating may be weighted with tungsten

• Inserted to stomach, duodenum or jejunum


15

LONG, SMALL BORE TUBES

• Introduced through the nose and passed through the esophagus and stomach into the intestinal tract.

• Used primarily for feeding

• Can be used to aspirate intestinal contents-ie. gas and fluid (Decompression) to prevent intestinal obstruction due to peristalsis, prevents vomiting, reduces tension at the incision line and prevents obstruction.


16

Insertion of a Nasogastric

Tube

Healthcare Professional Responsibilities

*Insertion of NGT by an RN depends on area of practice. Not all

RNs in every area are permitted to insert NGTs. Please check individual unit policies.


17

NGT insertion, irrigation, removal

You may watch this 10 minute video on insertion, irrigation, and removal of an NGT.

http://www.youtube.com/watch?v=vVEYfRmrCvQ

http://www.youtube.com/watch?v=vVEYfRmrCvQ


18

Healthcare Professional Responsibilities

• Verify Order

• Wash hands thoroughly

• Identify your patient using TWO patient identifiers. (Name and DOB and/or MR#)


19

Preparation, Patient Assessment

• LOC

• Ability to cooperate

• Medical Dx

• Lab values, VS, I&O

• Past medical Hx

• Teaching needs


20

Preparation Physical

Assessment

Abdomen

Oral Cavity

Inspect

Nares

and


21

NGT Insertion

This 3 minute video provides detail on NGT insertion:

http://www.wonderhowto.com/how-to-perform-nasogastric-tube-insertion-259833/















22

• Time insertion of tube with

swallow

• Check tube placement

• Monitor for respiratory distress have suction in reach! O2 sats, gasping, wheezing

• Never force tube

• If coughing begins, immediately with advancement of the tube, pull back to the naris right away and allow the patient to recover

Considerations regarding insertion


23

Tape Tube In Place

• Tear one end of tape

lengthwise

• Tape (whole end) to top of nose

• Wrap tails around tube

• Tape to nose

• Rubber band and pin to clothing


24

Confirming Placement

• Gold Standard is to confirm placement by CXR. The only reliable method for determining accurate placement of orogastric/nasogastric tubes is radiography.

• Tube placement is confirmed prior to any use of the tube for suction, irrigation, medication admin. or feedings.

• Malposition of feeding tubes and aspiration are the greatest risks with enteral nutrition. (Metheny)


25

Confirming Placement - Other Methods

• Attach syringe with 10-20 ml of air to end of tube: Inject air while auscultating over the epigastrium. Listen for “whooshing” sound.

• Aspirate stomach contents

• Measure tube length

• Ask patient to talk (if appropriate)

• Look in mouth for curled tube


26

Healthcare Professional Responsibilities:

Suction/Decompression

• Tube for decompression will be attached to Intermittent Suction.

• Keep suction setting between 20-80mm Hg.

• Continuous suction greater than 25mm Hg can cause damage to the gastric mucosa.


27

Set Up Suction Machine

Portable Suction Machine

Wall Suction

1. Select type of suction machine

2. Attach suction tubing to machine

3. Test Suction Machine

4. Attach End of enteral tube to suction machine


28

Connect Tubing to Suction

1. distal end of tube gets connected to suction tubing

2. Suction tubing

3. Turn on suction machine intermittent/continuous


29



• Do not clamp or plug the vent lumen.

• A soft hissing sound will be heard from the vent lumen if it’s patent.

• Empty canister every shift and prn- record amount on I&O

• Change canister if full or every 24 hours.


30



• Monitor electrolytes.

• Inspect gastric drainage for consistency, amount and odor.

• If no drainage, check suction equipment.

• Monitor skin around insertion points for any excoriation.


31

Irrigation of a Suction Tube

WATER

60 ml PISTON SYRINGE

1. Gather supplies 2. Turn off Suction 3. Disconnect Tubing 4. Instill 30 ml sterile water 5. Reattach suction & turn on

suction to intermittent or clamp


32


Irrigation

• Review irrigation schedule.

• Always measure the amount of irrigant used, to maintain an accurate intake and output record.

• Provide mouth care and nasal care.

• Check tape that secures tube frequently to prevent misplacement.

• Assess bowel sounds to verify GI Function.


33


Nutrition

• Assess for bowel sounds before feeding

• Monitor for abdominal distention • Maintain head of the bed at 30 to 45 degrees

continuously to prevent aspiration. Tube feeding solutions and tubing should be changed every 24 hours, or more frequently if the feeding requires it.

• Check for NG tube placement is performed before initiating the feedings and every 4 hours during continuous feedings.

• Clients may ambulate during feedings.


34


Continuous feedings

– Measure gastric contents every 4 hours.

– Administer feeding with a pump.

– Flush with 30-60ml of water every 4 hours.

– Monitor Intake and output.


35

HCP Responsibilities: Intermittent

Feedings

• Measure residual gastric contents. If residual measures more than twice the amount infused, feeding should be held and physician notified.

• Recheck in 1hour.

• Flush with 30ml of water to check for patency of tube.


36

HCP Responsibilities: Intermittent Feedings

• Allow gravity to help the formula flow over 30-45min. Infusing faster can cause bloating, cramps, or diarrhea.

• For intermittent feedings, have patient maintain a semi fowlers position this position for 30min-1hr afterwards.

• Begin intermittent feedings with a low volume

• When tube feeding complete flush with 30-60ml of water to maintain patency of tube.


37

Complications related to tube feedings:

• Bloating

• Diarrhea

• Vomiting

• Contamination

• Constipation

• Mechanical malfunction

• Metabolic disturbances

• Cramping

• Nausea

• Infection


38

Medication Administration via Nasogastric

Tube

• Check MD order

• Check to be sure medications can be crushed or given through a tube (ie.enteric coated is never crushed, consult pharmacist for an acceptable alternative, may be a liquid form of medication).

• Follow 5 rights of Medication Administration.

• Disconnect tube from suction or feeding.

• Aspirate stomach contents- if less than 100cc of contents, reinstill back to patient.


39

Medication Administration

• Always consider liquid form medications.

• Never combine medications

• Verify tube placement

• Dissolve crushed medications in 60 ml water

• Attach catheter tip syringe with medication to tube and allow to flow by gravity

• Instill 10 ml water into syringe barrel following administration

• Clamp tube – do not reconnect to suction for 20-30 minutes – may resume feeding

• Document!


40

Removal of a NG Tube

• STEP 1:

Assess and prepare patient

• STEP 2:

Wash hands, don gloves – Flush with 20 – 30 ml NS follow 20 – 30 ml air

• STEP 3:

Loosen tape


41

Removal of Tube

STEP 4: Have patient take a deep breath and hold, remove tube by rolling tube around your gloved hand, invert glove and discard


42

Transabdominal/Enterostomal Tubes

Gastrostomy - G tube, PEG (Percutaneous Endoscopic Gastrostomy)

Jejunum - J-tube, J-PEG/PEJ (Percutaneous Endoscopic Jejunostomy)

MD places tube surgically

Held in place by bolster &/or balloon

Bolster Balloon

Medication/

Feeding Port Fill balloon

only


43

Additional Considerations Peg/Pej Tubes

• Tube Exit Site Care:

• Provide daily skin care

• Remove dressing by hand. Never use scissors.

• Clean tube around exit site. Observe site for maceration or excoriation.

• Anchor tube with tape to prevent pulling


44

DOCUMENT!

• Tube type, size and location

• Confirmation of placement

• Drainage or aspirate (residuals) amount, color and consistency

• Irrigation type and amount

• Suction- type and level (i.e. low intermittent)

• Feeding- type and amount

• Patient tolerance

• Patient/ Family education and response


45

References

• Lynn-McHale, Debra J. & Karen K. Carlson, AACN Procedure Manual for Critical Care, 4th ed. 2001, pp. 683-685

• Metheny NA, Titler MG. Assessing placement of feeding tubes. Am J Nurs. 2001; 101(5):36–45.

• Nettina, S.M. (2001). The Lippincott manual of nursing practice, New York:Lippincott

• NSLIJ Policy and Procedure Manual: Nasogastric Tube, Care of a patient with


46

Post Test

It is required that you take an online post test after module completion.

Click on this Link to Access:

https://nslijhp.northshorelij.com/nursing/EWD/Pages/NursingQuizSystemSYS.aspx?user_facility=system&user_quiz=system-enteral-tubes

Passing score = 100%








113_EnteralTube.1.8.2014._IFN.ICP.pdf

Documents

Transcript of 113_EnteralTube.1.8.2014._IFN.ICP.pdf