ATI/NCLEX Review Questions on Gastrointestinal Intubation and Feeding Tubes

Gastrointestinal Intubation Definitions

• Intubation involves inserting a tube into a body structure, particularly the stomach or intestine, through the mouth or nose.
• Bolus feeding delivers a specific amount of formula at scheduled intervals.
• Continuous feeding delivers formula continuously over a period of time.
• Cyclic feeding combines continuous feeding for part of the day with bolus feeding for the remainder.
• Decompression removes gas or liquid contents to relieve pressure from the stomach or bowel.
• Dumping syndrome is a condition characterized by rapid gastric emptying that can occur after gastric surgery.

Types of Gastrointestinal Tubes

• An orogastric tube is inserted through the mouth into the stomach and is used for lavage and gavage.
• A nasogastric tube is inserted through the nose into the stomach and is commonly used for feeding and decompression.
• A gastrostomy tube (G-tube) is surgically placed directly into the stomach for long-term feeding.
• A jejunostomy tube (J-tube) is inserted into the jejunum for feeding, bypassing the stomach.
• A nasointestinal tube is inserted through the nose into the intestine and is used for feeding and decompression.

Indications for Intubation

• Intubation facilitates nourishment for those unable to eat orally.
• It facilitates medication administration for those unable to swallow.
• It allows diagnostic testing to obtain gastric secretions for analysis.
• It allows lavage to remove harmful substances from the stomach.
• It allows decompression, relieving pressure caused by gas or fluid accumulation.

Assessments Before Tube Insertion

• Assess the patency of the nasal passages prior to nasogastric intubation via a nasal assessment.
• Assess the gag reflex, especially in older adults or those with neurological disorders.
• Measure from the nose to the earlobe to the xiphoid process via NEX measurement to determine proper tube length.
• Check skin integrity for any issues around the insertion site to prevent complications.
• Review the patient's medical history for conditions that may affect intubation.

Ethical Considerations in Tube Feeding

• Informed consent requires ensuring that clients or their decision-makers understand the risks and benefits of tube feeding.
• End-of-life care includes discussing the implications of tube feeding in clients with terminal conditions and respecting their choices.
• Nutritional needs include tailoring tube feeding formulas to the specific needs of older adults, considering malabsorption and other conditions.
• Decision-making capacity includes involving appropriate parties in decisions regarding tube feeding for clients lacking capacity.
• Cultural sensitivity requires awareness of cultural beliefs regarding nutrition and hydration at the end of life.

Tube Feeding Administration

• Understand different feeding schedules (bolus, continuous, cyclic) and their applications by checking the feeding schedules.
• Assess gastric residual volumes to prevent complications such as aspiration by monitoring gastric residual.
• Monitor for imbalances, especially in older adults receiving tube feedings by checking fluid and electrolyte management.
• Watch for changes in behavior that may indicate discomfort or complications by behavioral monitoring.
• Teach clients and caregivers about tube feeding management and signs of complications through patient education.

Insertion Techniques

• Orogastric intubation involves inserting the tube through the mouth, ensuring proper placement in the stomach.
• Nasogastric intubation involves inserting the tube through the nose, using the NEX measurement for guidance.
• It is important to understand the surgical procedure and indications for jejunostomy tube (J-tube) placement.
• In some cases, a stylet may be useful for facilitating the insertion of flexible tubes.
• Monitor the patient post-insertion for complications such as displacement or blockage of the tube.

Jejunostomy Tubes

• A jejunostomy tube is surgically inserted into the jejunum of the small intestine, primarily for feeding and medication administration.
• It is used when patients cannot swallow or require long-term nutritional support.
• The tube can also be used for diagnostic purposes, such as obtaining secretions for testing.
• It aids in performing a lavage to remove substances from the stomach or intestines.
• Jejunostomy tubes help in decompression by removing gas and liquid contents from the gastrointestinal tract.
• They can control gastric bleeding through a process known as compression or tamponade.

Types, Sizes and Purposes of Gastrointestinal Tubes

• Gastrointestinal tubes vary in size, construction, and purpose, categorized by their insertion location and distal end location.
• Common types include orogastric, nasogastric, nasointestinal, and transabdominal tubes, each serving specific medical needs.
• The French scale is used to measure the diameter of these tubes, with each number equaling approximately 0.33 mm; larger numbers indicate larger diameters.
• Tubes can be single-lumen or multi-lumen, affecting their functionality and application in clinical settings.
• Tube choice depends on the patient's condition, the duration of use, and the required therapeutic intervention.
• Orogastric tubes are used in emergencies to remove toxic substances from the stomach, allowing for larger debris removal.
• Nasogastric tubes are smaller, can remain in place for extended periods, but may cause discomfort and irritation.
• Levin tubes are a common type of nasogastric tube, used for decompression and feeding.
• Sump tubes have a double lumen design, reducing the risk of obstruction and allowing for venting during suction.
• Nasointestinal tubes are longer than gastric tubes, allowing placement beyond the stomach into the small intestine.
• They are primarily used for providing nutrition and decompression of the small intestine.
• Dobhoff tubes are a common type, made of flexible materials to enhance comfort and reduce reflux risk.
• These tubes often have a weighted tip to facilitate passage through the gastrointestinal tract.
• Transabdominal tubes, such as G-tubes and J-tubes, are used for patients requiring long-term nutritional support.
• G-tubes are inserted surgically or endoscopically and are anchored to the abdomen for stability.
• J-tubes are inserted through a PEG tube and are designed for feeding directly into the jejunum.
• These tubes are preferred for patients who cannot tolerate oral feeding for extended periods.

Assessments Prior to and After Intubation

• Nurses must conduct a focused assessment before tube insertion, evaluating the patient's level of consciousness, weight, bowel sounds, and abdominal distention.
• This assessment helps determine the appropriate type of tube and insertion technique.
• Understanding the patient's medical history and current condition is crucial for successful intubation.
• After insertion, monitoring the volume and type of fluid instilled is crucial for assessing the procedure's effectiveness.
• Appearance and volume of returned drainage provide insights into the patient's condition and the tube's patency.
• Client response is a key indicator of the procedure's success and comfort level.
• Accurate data collection aids in determining fluid balance, is essential for patient care.
• Regular monitoring reduces the risk of infection by minimizing the transmission of microorganisms.
• Documentation of these parameters is vital for legal and medical records, including date, time, and specific details about the procedure.
• Documentation should reflect the patient's response and any changes in condition post-procedure.
• Clear and concise records help in future assessments and comparisons, with legal compliance ensured.
• Documentation serves as a communication tool among healthcare providers.

Maintenance and Troubleshooting

• Proper technique is essential to minimize discomfort and complications during insertion; proper technique includes patient airways
• Gastrointestinal tube maintenance includes ensuring the tube is patent and functioning as intended after insertion.
• Regular monitoring and maintenance of the tube are necessary to prevent obstruction and ensure effective therapy.
• Nurses must maintain oral hygiene at least twice daily to prevent infections and promote comfort.
• The patient needs to maintain the proper nutrition; Intermittent feeding is a method used to provide nutrition at scheduled intervals, ensuring the client receives adequate nourishment.
• Proper techniques in feeding can prevent complications such as gastric reflux and aspiration.

NG Tube Specifics

• Nasogastric tubes are commonly inserted by nurses and require ongoing management to ensure patency and therapeutic effectiveness.
• Follow a systematic approach for assessment, including checking gastric residuals and overall client condition for tube feedings.
• Pre-intubation assessment includes evaluating the client's level of consciousness, weight, bowel sounds, and ability to swallow.
• Assess the integrity of nasal and oral mucosa to prevent complications during tube insertion.
• Evidence-based methods for confirming the distal location of a nasogastric tube include X-ray verification and monitoring external tube length.
• Clients often feel anxious about swallowing a tube; explaining the procedure can alleviate fears.
• Establishing a signal for the client to indicate discomfort during insertion can empower them and reduce anxiety.
• Inspect nostrils for size, shape, and patency after clearing nasal debris.
• The NEX (nose-to-earlobe-to-xiphoid) is critical for determining the appropriate tube length.
• The nurse's primary goals during insertion are minimizing discomfort and ensuring the tube is placed in the stomach, not the respiratory tract.
• After initial insertion, verify tube placement by aspirating fluid and testing pH with a large-volume syringe.
• Stomach fluid typically has a pH of 5 or less, while small intestine secretions have a pH of 6 or greater.
• Nasogastric tubes can be connected to suction for gastric decompression or used for tube feeding.
• Continuous or intermittent suction may be employed based on the clinical situation.
• Regularly assess the tube's position and patency to prevent complications.
• Educate clients on the purpose and care of the tube to enhance compliance and comfort.
• Gastric decompression involves using a nasogastric tube to remove gastric contents, allowing the tube to move by gravity through the pyloric valve.
• Continuous suctioning with an unvented tube can lead to adherence to the stomach mucosa, causing irritation and drainage issues.
• A vented tube or intermittent suction minimizes these complications, ensuring effective drainage.
• Suction settings are typically prescribed by a physician, with low pressure (40 to 60 mm Hg) being standard for safety.
• The tube must be clamped during ambulation or after medication administration to prevent complications.
• Tube patency is crucial; ice chips or sips of water can help dilute gastric secretions for clients who are NPO.
• Excessive water intake can lead to electrolyte depletion, so it must be administered cautiously.
• Nurses should frequently assess tube patency by monitoring drainage volume and characteristics, and observing for obstruction symptoms like nausea and distention.
• Common causes of obstruction include kinks in the tubing, displacement, or blockage by solid particles or thick mucus.
• Interventions may include repositioning the client, checking suction settings, or irrigating the tube with a medical order.

Tube Removal

• Nasogastric tubes are removed when the client's condition improves or if they become obstructed.
• Larger diameter tubes are typically changed every 2 to 4 weeks, while smaller tubes are changed every 4 weeks to 3 months.
• Pediatric clients require more frequent changes due to fragile tissue and higher infection risk.
• A trial period may be prescribed before permanent removal, allowing the client to consume oral fluids while monitoring for symptoms.
• If symptoms develop, the tube can be easily reconnected to suction, minimizing discomfort.

Enteral Nutrition

• Enteral nutrition provides nourishment through the stomach or small intestine, bypassing the oral route.
• It is typically administered via nasogastric, nasointestinal, or transabdominal tubes, with nasointestinal tubes being preferred for liquid formulas.
• The choice of tube depends on the patient's condition and the duration of feeding required.
• Insertion techniques for nasointestinal tubes are similar to those for nasogastric tubes, with some modifications due to tube construction.
• The NEX measurement (Nose to Ear to Xiphoid) is used to estimate the required length of the tube, adding an additional 9 inches (23 cm) for intestinal placement.
• Proper positioning and client preparation are essential for successful tube placement.

Gastrostomy Tubes

• Hand hygiene is critical to reduce the transmission of microorganisms during gastrostomy care.
• Regular assessment and replacement of gauze dressings are necessary to prevent infection and promote healing.
• Inspect the skin around the tube daily for signs of irritation or infection, and apply skin barrier ointments as needed.
• Cleaning the site with half-strength hydrogen peroxide or saline is recommended initially, transitioning to soap and water after one week.
• New technologies, such as electromagnetic systems, are being developed to enhance the safety and efficacy of nasoenteric tube placement.
• These systems use modified feeding tubes and external receivers to provide real-time feedback on tube placement, reducing the need for radiographic verification.
• Such advancements aim to improve patient outcomes and streamline the feeding process.
• The external bumper should be slid down to be flush with the skin to stabilize the tube and prevent migration.
• Avoid placing dressing materials under the arms of the external bumper to prevent pressure on the internal bumper, which can damage tissue.
• Weekly replacement of water in the balloon beneath the bumper is essential; use a Luer-tip syringe to maintain inflation and prevent tube migration.
• Secure the G-tube to the abdomen using tape, an abdominal binder, or a commercial tube stabilizer to maintain its position and prevent dislodgment.
• Regular assessments should be made to ensure the tube is not kinked and that the skin is not stretched, which helps maintain tube patency and skin integrity.
• In case of accidental extubation, a Foley catheter can be inserted to maintain temporary access to the stomach if done within 3 hours.
• Leaks can occur due to disconnection between the feeding delivery tube and the G-tube, leading to inadequate feeding.
• Clamping the G-tube while feeding can cause leaks and should be avoided during tube feeding.
• Mismatched sizes between the G-tube and stoma can lead to leaks and complications.
• Increased abdominal pressure from formula accumulation, retching, sneezing, or coughing can also cause leaks.
• Underinflation of the balloon beneath the skin can lead to tube migration and leaks.
• An optimal stoma location is crucial to prevent leaks and ensure proper function.

Tube Feeding Indications

• Tube feedings are indicated when oral feedings are impossible or unsafe, such as in unconscious patients or those with swallowing difficulties.
• They are also used post extensive mouth surgery or in patients with esophageal or gastric disorders.
• Tube feedings can be administered through nasogastric, naso-intestinal, or transabdominal tubes, each with specific advantages and disadvantages.
• The technique for administering tube feedings is detailed in Skill 29-4, emphasizing the importance of proper technique for patient safety.
• Tube feedings utilize the body's natural reservoir for food, which can help reduce the risk of enteritis.
• Gastric feedings can increase the risk of gastric reflux due to the volume and retention of food in the stomach.
• Tube feedings can be beneficial for patients with intact stomach or intestinal function, providing necessary nutrition when oral intake is not possible.
• Each type of feeding tube has its own advantages, such as low incidence of obstruction for nasogastric tubes and long-term use for gastrostomy tubes.
• Risks include potential for aspiration, skin breakdown, and infection at the tube site, necessitating careful monitoring and care.
• Gastric feedings can lead to gastric reflux, while intestinal feedings may cause dumping syndrome, characterized by weakness and nausea due to rapid nutrient delivery.
• Specialty formulas are available for specific medical conditions, ensuring tailored nutritional support for patients.
• Regular assessment and care of the tube site are crucial to prevent complications.
• Tube-feeding formulas are tailored to meet individual nutritional needs based on weight, medical conditions, and therapy duration.
• Standard isotonic formulas provide approximately 1.0 kcal/mL and are suitable for clients with normal digestion.
• High-calorie and high-protein formulas are available for clients with increased nutritional needs or fluid restrictions.
• Fiber-containing formulas help normalize bowel function, while partially hydrolyzed formulas are designed for clients with impaired digestion.
• Specialty formulas are available for specific conditions such as diabetes or renal failure, ensuring appropriate nutritional support.
• Common products include Osmolite, Jevity, and Criticare HN, which are primarily intended for tube feedings.
• Tube feedings can be administered via bolus, intermittent, cyclic, or continuous schedules, each with specific protocols.
• Bolus feedings involve administering 250 to 400 mL of formula in less than 30 minutes, which can cause gastric discomfort and increased reflux risk.
• Intermittent feedings are given over 30 to 60 minutes, mimicking meal times and reducing bloating compared to bolus feedings.
• Cyclic feedings provide nourishment for 8 to 12 hours, often during the night, allowing for oral intake during the day.
• Continuous feedings are administered at a constant rate, ensuring steady nutrient delivery and minimizing the risk of complications.
• Regardless of the schedule, feeding administration sets should be replaced every 24 hours to prevent infection.
• Daily assessments for clients receiving tube feedings include monitoring weight, fluid intake/output, bowel sounds, lung sounds, temperature, and the condition of mucous membranes.
• Aspiration risk includes; gastric residual volume is a critical measure to assess the client's tolerance to feeding.
• A residual volume exceeding 100 mL or 20% of the previous hour's feeding volume may indicate the need to delay feeding to prevent complications such as aspiration and pneumonia.
• Feeding tubes, especially those smaller than 12 French, are prone to obstruction; maintain patency.
• Common causes include using formulas with large-molecule nutrients and administering formula at a rate less than 50 mL/hour.
• To maintain patency, it is recommended to flush feeding tubes with 30 to 60 mL of water before and after feedings or medications, and every 4 hours during continuous feeding.
• If an obstruction occurs, the nurse may attempt to clear it using warm water in a 30- to 60-mL syringe. If unsuccessful, a solution of fluid-activated pancreatic enzyme combined with sodium bicarbonate may be used, requiring a medical order.
• Tube feedings are approximately 80% water, but clients often require additional hydration. The nurse will assess.
• Clients receiving enteral feeding may experience various common problems, including gastrointestinal discomfort and tube-related complications. The nurse will manage these problems.
• Enteral feeding is a method of delivering nutrition directly to the gastrointestinal tract, often used for patients who cannot consume food orally.
• It involves the use of feeding tubes, which can be inserted nasally, orally, or surgically, depending on the patient's needs.
• The nurse plays a critical role in monitoring and adjusting the feeding plan based on the patient's response and nutritional needs.

Common Problems

• Problems can arise from the feeding formula, tube mechanics, or patient-specific factors.
• Common issues include diarrhea, nausea, vomiting, aspiration, and constipation, often linked to the formula's concentration or administration speed.
• The management of the common issues emphasize/ensure the need for prompt reporting and adjustments.
• Solutions include diluting formulas, adjusting feeding rates, and ensuring proper tube placement to minimize complications.
• Nurses should monitor urine output and lung sounds to assess fluid balance and potential complications from overfeeding.
• Regular hand hygiene and equipment changes are essential to prevent bacterial contamination and ensure patient safety.
• Discharge planning for patients requiring tube feedings includes providing written instructions for caregivers.
• Instructions should cover equipment procurement, feeding schedules, and signs of complications to report; this is important for home care.

Decompression

• Intestinal decompression is performed to relieve pressure in the gastrointestinal tract, often preventing the need for surgical intervention.
• It is indicated in cases of bowel obstruction, ileus, or other conditions causing distension and discomfort.
• The insertion technique is similar to that of a nasogastric tube, requiring careful monitoring of the tube's progression into the intestine.
• The use of a tungsten-weighted tube aids in advancing the tube through the pyloric valve into the small intestine, utilizing gravity and peristalsis.
• Positioning the patient correctly post-insertion is crucial; alternating positions can facilitate tube movement through intestinal curves.
• Regular X-ray confirmation may be required to ensure the tube is in the correct location, providing objective evidence of its placement.
• The removal process must be gradual to avoid complications, with the tube being withdrawn slowly to navigate intestinal curves.
• Post-removal care includes nasal and oral hygiene to ensure patient comfort and prevent infection.
• Nurses may identify various nursing diagnoses based on client care data, including malnutrition risk, feeding ADL deficit, and aspiration risk.
• Aspiration risk is defined as the inhalation of foreign objects into the trachea and lungs, often due to compromised protective reflexes (Nurseslabs, 2022).
• Other potential diagnoses include diarrhea and constipation, which can complicate the care of clients receiving tube feedings.
• Understanding these diagnoses is crucial for developing effective nursing care plans tailored to individual client needs.
• Regular assessment includes measuring gastric residual volume, auscultating bowel sounds, and palpating the abdomen for distention.
• Monitor the patient and control as necessary;
• Key interventions include securing the feeding tube to prevent migration and coiling excess tubing to avoid accidental extubation.
• The nurse must assess gastric residual volume before each bolus feeding to prevent overfeeding and potential aspiration.
• Maintain head elevation at no less than 30 degrees to promote gastric emptying and reduce aspiration risk.
• Keep the client in a high Fowler position to facilitate the movement of gastric contents toward the small intestine.
• Ensure a suction machine is available at the bedside for rapid response in case of vomiting.
• Document the client's response to tube feeding and any changes in their condition to inform ongoing care.
• Assess the client's comfort by asking about feelings of fullness, nausea, or vomiting, which can indicate the need for further intervention.
• Monitor the patient and control as necessary, that may require interventions.
• Evaluate the effectiveness of interventions by checking if gastric residual measures less than 500 mL and if bowel sounds are present and active in all quadrants.
• Gastrointestinal intubation involves placing a tube into the stomach or intestine via the mouth or nose for various medical purposes.
• Common reasons for intubation include obtaining diagnostic samples, performing gastric lavage, promoting decompression, and controlling gastric bleeding.
• Pre-intubation assessment includes evaluating the client's level of consciousness, weight, bowel sounds, and ability to swallow.
• It includes the assessment of the integrity of nasal and oral mucosa that is crucial to prevent complications during tube insertion.
• Nurses must be vigilant in monitoring and adjusting care plans accordingly for tube feeding problems.
• Nasogastric tubes (NG tubes) are used for various medical reasons, including gastric decompression, feeding, and medication administration.
• They are indicated in patients who cannot eat by mouth due to conditions such as stroke, surgery, or severe illness.
• Visual aids, such as diagrams of the anatomy, can help in understanding the insertion process.
• Gather all necessary equipment: NG tube, lubricant, syringe, suction machine, etc. for patients and nurses.
• Ensure the patient is in a comfortable position and explain the procedure to alleviate anxiety.
• Assess the patient's nasal passages and clear them if necessary.
• Establish a hand signal for the patient to indicate discomfort during the procedure.
• Warm the tube if it feels rigid to enhance flexibility and to promote effective and safe use.
• Importance of hand hygiene and using gloves to prevent infection for patents and nurses.
• Irrigate with correct solution: Irrigation of an NG tube is performed to maintain patency and ensure proper drainage.
• Document the appearance and volume of returned drainage to evaluate the effectiveness of the procedure.
• Monitor/provide care-importance of patient education regarding the purpose of irrigation and what to expect.
• A patient experiencing abdominal distention may show improvement after irrigation. Verify a medical order for tube removal is present and that the client understands the procedure. Identifying the client is essential to ensure the correct procedure is performed on the right patient; do not work with the wrong patient. Understanding the procedure helps in reducing anxiety and improving cooperation from the client; this is for both patient and nurse. Check medical orders for the type of nourishment, volume, and schedule before administration before tube feeding. Flush the feeding tube with water to maintain patency and prevent clogging as needed for tube feeding. As needed, a bolus feeding procedure can be done: Document the volume of formula and water administered for accurate intake records. Follow the same assessment and planning steps as for bolus feeding, with additional attention to equipment hygiene for continuous feeding. Following the safety procedure-Gradually open the clamp on the tubing to control the flow of the feeding formula so the patient does not suffocate or encounter an unsafe medical emergency. Provide oral hygiene at least twice daily to maintain oral health during continuous/intermittent tube feeding/bolus procedure.Document all procedures and client responses to ensure comprehensive care records.

Key steps

• Fill the feeding container with room-temperature formula to prevent cramping and discomfort during continuous/intermittent/bolus tube feeding.
• Monitor the client and control as necessary-Monitor the drip rate according to physician's orders and check at 10-minute intervals for any issues-continuous/intermittent/bolus tube feeding.
• All those receiving enteral feeding may experience various common problems, including gastrointestinal discomfort and tube-related complications.
• The health team will monitor for this-Monitor the client's weight to ensure it remains stable or reaches target weight as per nutritional goals/continuous/intermittent/bolus tube feeding.
• Provide and monitor the patient - continuous/intermittent/bolus tube feeding, they will need a daily fluid intake of 2,000 to 3,000 mL unless otherwise restricted.
• Maintain patient document and monitoring -Document the volume of gastric residual, type and volume of formula, and rate of infusion for continuous feedings/continuous/intermittent/bolus tube feeding