Gastrointestinal Intubation

• Gastrointestinal intubation involves placing a tube into the stomach or intestine.
• It is used to reduce problems from surgery or conditions affecting the GI tract, such as impaired peristalsis, vomiting, or gas accumulation.
• Tubes can be used for nourishment in clients who cannot eat.

Gerontologic Considerations

• Age-related reduction in laryngeal nerve endings diminishes gag reflex efficiency.
• Neurologic disorders like dementia, strokes, and Parkinson's disease can also depress the gag reflex.
• Long-term tube feeding in older adults with dementia raises ethical concerns.
• Refusal to eat may be intentional or unintentional, linked to depression, suicidal behaviors, or cognitive impairment.
• Adults with decision-making capacity, medical power of attorney, and the healthcare team are best equipped to weigh the risks and benefits of nutrition and hydration during care near the end of life.
• The client's choices concerning nutrition and hydration must be respected.
• Nurses should have current knowledge regarding the ethical and legal aspects of tube feedings.
• Prescriptions for tube-feeding formulas consider conditions like malabsorption syndromes or glucose intolerance.
• Older clients who experience malabsorption may see a benefit in lactose-free formulas.
• Formulations fortified with zinc, protein, and other nutrients can benefit clients who have or are at risk of developing pressure sores.
• Registered dietitians can offer help in the continuous evaluation of tube feedings at home and in long-term care facilities.
• In general, small, continuous feedings are tolerated best by seniors.
• Older adults are more prone to fluid and electrolyte abnormalities, perhaps leading to hyperglycemia; it's important to routinely evaluate capillary blood glucose levels while administering tube feedings.
• Monitor older adults for agitation or confusion, as these things may result in inadvertent removal of the tube, and might also signal fluid or electrolyte abnormalities.
• When instructing older adults or their caregivers on how to handle G-tubes, allot more time for information processing and practice sessions.
• Clients who need tube feedings after release may need a recommendation for skilled nursing care covered by Medicare/Medicaid or private health insurance.
• For older individuals with set incomes, dietitians can suggest recipes for less expensive, home-blended recipes that fulfill their dietary requirements.

Intubation Defined

• Intubation is the insertion of a tube into a body structure.
• Gastrointestinal intubation involves inserting a tube into the stomach or intestine through the mouth or nose.
• Orogastric intubation means inserting a tube through the mouth into the stomach.
• Nasogastric intubation refers to the insertion of a tube through the nose into the stomach.
• Nasointestinal intubation involves inserting a tube through the nose into the intestine. A tube may also be inserted into a surgically created opening, otherwise known as an ostomy.
• Prefixes such as gastrostomy highlight the anatomical location of the ostomy, for example an artificial opening into the stomach.

Purposes for Gastric and Intestinal Tubes

• Performing a gavage by, in essence, providing nutrition
• Administering medications the patient cannot ingest
• Obtaining a sample of secretions for diagnostic testing
• Performing a lavage (removing substances from the stomach)
• Promoting decompression (removing gas and liquid contents)
• Controlling gastric bleeding through compression or tamponade

Types of Tubes

• Gastric and intestinal tubes vary in size, construction, and composition based on their intended use.
• Tube diameter is measured using the French scale (each number equals approximately 0.33 mm; larger numbers mean larger diameters).
• Tubes may be identified by insertion location (mouth, nose, abdomen) or distal end location (stomach, intestine).

Orogastric Tubes

• Orogastric tubes (e.g., Ewald tube) are inserted through the mouth into the stomach.
• They are used in emergencies to remove toxic substances.
• Large diameter allows removal of pill fragments and stomach debris.
• Insertion occurs through the mouth due to its size.

Nasogastric Tubes

• Nasogastric tubes are placed through the nose into the stomach.
• They are smaller in diameter but larger and shorter than the nasointestinal tubes.
• Some have multiple lumens (channels).

Levin Tube

• the Levin tube is a single-lumen gastric tube.
• it has uses like decompression

Gastric Sump Tubes

• Gastric sump tubes are double-lumen tubes.
• Sump tubes are used remove fluid from the stomach.
• The second lumen vents to prevent the stomach wall from adhering to and obstructing drainage openings.
• Nasogastric tubes can cause discomfort and potential tissue irritation/breakdown in the nose and throat.
• Gastric tubes may dilate the esophageal sphincter, potentially causing gastric reflux.

Nasointestinal Tubes

• Nasointestinal tubes are placed through the nose for distal placement below the stomach.
• Extra length allows placement in the small bowel.
• They can provide nourishment or remove gas and liquid.

Feeding Tubes

• Nasointestinal feeding tubes (e.g., Dobhoff tube) are small in diameter and made of flexible materials.
• They can stay in the same nostril for extended periods.
• They reduce risk of gastric reflux by delivering nutrition beyond the stomach.
• Narrow tubes can curl during insertion and may require a stylet (metal guidewire).
• They have weighted tips to aid in descending past the stomach.
• Checking the placement of the distal end is more difficult.
• Preferred choice for comfort offering continuous infusion of nutrition.

Intestinal Decompression Tubes

• Intestinal decompression is used when a client has a partial or complete bowel obstruction.
• These tubes have a double lumen and weighted tip.
• One lumen suctions intestinal contents, and the other acts as a vent to reduce suction-induced trauma to intestinal tissue.
• The radiopaque tip's progress is monitored by X-ray.

Transabdominal Tubes

• Transabdominal tubes are placed through the abdominal wall to access the GI tract.
• Examples include gastrostomy tubes (G-tubes) and jejunostomy tubes (J-tubes).
• A percutaneous endoscopic gastrostomy (PEG) tube is inserted under endoscopic guidance and anchored with internal and external crossbars (bumpers).
• A percutaneous endoscopic jejunostomy (PEJ) tube is passed through a PEG tube into the jejunum.

Nasogastric Tube Management

• Nursing responsibilities include keeping the tube patent, implementing its prescribed use, and removing it when no longer needed.

Nasogastric Tube Insertion

• Involves client preparation, preintubation assessments, and tube placement.
• Explain the procedure to ease anxiety, and provide instructions. The nurse can help patients to feel more in control of the situation by setting up a signal, such as the client lifting a hand, to signify they need to stop the passage of the tube.

Preintubation Assessment

• Level of consciousness
• Weight
• Bowel sounds
• Abdominal distention
• Integrity of nasal and oral mucosa
• Ability to swallow, cough, and gag
• Any nausea and vomiting
• Goals are to establish a baseline, determine the best nostril to use, and the length to which the tube will be inserted.

Nasal Inspection

• The client should clear nasal debris, and the nurse inspects each nostril for patency and any abnormalities.

Nasogastric Tube Measurement

• Markings on tubes may not be accurate.
• Measure from nose to earlobe to xiphoid process (NEX) and mark the tube. The first mark on the tube indicates the distance to the nasal pharynx while the second indicates how much is needed to reach the stomach.

Nasogastric Tube Placement

• Nurse concerns relate to discomfort, preserving nasal tissue integrity, and proper tube location.
• pH testing of aspirated liquid cannot always be relied on, because of the possible contamination of pH by things such as saliva.
• After confirmation they secure placement.

Nasointestinal Feeding Tube Insertion.

• They wash hands and put on gloves.
• Obtain a flexible small-gauge feeding tube with a stylet.
• They should follow manufacturer's suggestions for activating the lubricant bonded to the tube.
• Secure the stylet within the tube.
• Insert the tube into the nose until it reaches the second mark.
• Watch for signs of respiratory distress.
• Aspirate fluid and determine pH.
• Compare the color on the test strip to the reagent strips.
• Stomach fluid usually sits at a pH of 5 or less, while secretions from the small intestine generally have a pH of 6 or higher.
• Ambulate or position the client on the right side for at least one hour or the time specified in the agency's policy to move the tube into the stomach.

Use and Maintenance of Nasogastric Tubes

• They are connected to suctioning for gastric compression used for tube feeding.

Gastric Decompression

• Suction can be continuous or intermittent.
• With unvented tubes the mucosa might attach making the tube adhere, causing irritation and interfering with drainage. With a vented tube the suction is less prone to this happening.

Promoting Patency

• Even with intermittent suctioning, the tube may become obstructed. Giving ice chips or occasional sips of water to a client who is otherwise NPO (receives nothing by mouth) promotes tube patency.

Restoring Patency

• Assess tube patency frequently by monitoring the volume and characteristics of drainage and observing for signs and symptoms suggesting an obstruction (nausea, vomiting, and abdominal distention). Inspection of the equipment helps identify possible causes for the assessment findings.

Enteral Nutrition

• This is nourishment provided through the stomach or small intestine rather than the mouth.

Inserting a Nasointestinal Feeding Tube

• Nasointestinal tubes are similar to nasogastric tubes.
• Estimate the length of the tube required for placement by determining the NEX measurement and adding 9 inches (23 cm).

Managing a Gastrostomy

• They wash hands, and wear gloves.
• Assess and replace the gauze dressing over a new gastrostomy if it becomes moist.
• Assess the skin around that tube on a daily with checking that the sutures holding the place.
• Check each day that the tube remains untampered with.
• Rotate the direction of the external bumper 90 degrees or to relieve pressure.
• Slide the external Bumper down to the skin. Avoid the use of dressing between the external Bumper.
• Replace the tube’s water balloon on a weekly basis that is below the number. Secure the tape to the site or with bandage to prevent it.
• Make sure that the tube remains not kinked and stretched.

Transabdominal Tube Management

• The nurse is responsible for assessing and caring for transabdominal tubes such as G-tubes and J-tubes.

Tube Feedings

• Oral nutrition is always best, tube feedings are used when this is not an option. Tube feedings are used when a patient has an intact stomach.

Benefits and Risks of Tube Feedings

• Tube feedings can be delivered through a nasogastric, nasointestinal, or transabdominal tube, each with its advantages and disadvantages.
• Using the body's natural reservoir in the stomach has advantages but increases the potential of gastric reflux.
• Tubes positioned reduced potential for this reflux.

Formula Considerations

• The type of tube, formulas differ.
• Standard, High-calorie, High-protein, Fiber-containing, and Partially hydrolyzed.
• Most formulas provide 0.5-2.0 kcal/mL with 750-800 mL of water per liter.

Tube-Feeding Schedules.

• Tube Feedings may be administered on bolus, intermittent, cyclic, or continuous schedules.

Bolus Feedings

• Bolus feeding usually involves 250 to 400 mL of formula administration. It is bad because it extends the fast to the point for reflux, though, mimics the natural feeling of eating.

Intermittent Feedings.

• Gradual instillations the meal. They usually take place over period 30 to 60 minute increments. Can do from from a feeding pump.

Cyclic Feedings

• Has a continuation when the client continues with adequate nutrition.
• A tube is given to the patient for sleep.

Continuous Feedings

• Continuous feeding occurs around 1.5 mL per minute, it has advantages like it does not the need of the stomach.
• Feed pump is continuous because the pump needs to exist.

Client Assessment

• Assess client daily following tube feeding.
• Weight, fluid intake and output, bowel sounds.
• Assesses each day their patterns and gastric residue. And is a rate.
• It increases physiology.

Nursing Management.

• It reduces client hydration.
• Has common formulated problems.

Maintaining the Tube.

• Tube-feeding the same that are at prone- obstruction.
• Have large molecule is what formula and the more of that formula what creates obstruction.

Troubleshooting Poorly Draining Nasogastric Tube

• The cause may vary from simple physical obstruction, the drainage holes is is it connected the right way.

Checking the Gastric Residue

• If you wash hands, the first step is to make sure that there isn’t any contamination.

Clearing and Obstruction

• Occasionally, it is possible to clear the tube with a solution of warm water in a 30- to 60-mL syringe.
• Pancreatic enzyme used to do unclog.
• Many systems, the BIONX has stems that are wire.
• Remove them.

Providing Adequate Hydration.

• Water that is 80 minutes more.
• Increase in weight.

Handling Problems.

• Be sure that problems are resolved at the correct time, be more sure of them.

Preparing for Home Care.

• The client requires assistance on the problems and on what does and doesn’t need to be done.

Nasointestinal Decompression.

• This is used with client that in most case are the needs

Nasointestinal Decompression Tube Insertion

• It is in the same way of that of the nasal gastric tube.
• The passage is that that is monitored to the the patients passage.

Inserting and Nasointestinal Decompression Tube.

• Assemble what is needed because the patient needs to be able to stay in a location that is safe for them, doing that makes it work.

Nursing Implications

• Depending on what the client requires, the nurses makes sure that what is going on is right.