Gastrointestinal Intubation

• Gastrointestinal intubation involves inserting specialized tubes into the digestive tract for therapeutic and diagnostic purposes.

Learning Objectives

• Understand different types of gastrointestinal tubes and their purposes.
• Identify proper insertion techniques for various GI tubes.
• Recognize potential complications associated with GI tube placement.
• Describe nursing responsibilities in GI tube management.
• Demonstrate proper documentation procedures for GI tube care.

Introduction to Gastrointestinal Intubation

• Critical skill in emergency and routine care.
• Provides access for medication administration.
• Enables feeding when oral intake is compromised.
• Facilitates gastric decompression.
• Allows for specimen collection.
• Essential for preventing aspiration.
• A foundational skill for patient care across multiple clinical settings.

Key Structures for Tube Placement

• Key structures involved are the esophagus, stomach, pylorus, duodenum, jejunum, and ileum.
• The esophagus is a muscular tube connecting the mouth to the stomach.
• The stomach is the main digestive organ and a site for NG tube placement.
• The pylorus is the gateway between the stomach and duodenum.
• The duodenum is the first part of the small intestine, common for NJ tube placement.
• The jejunum is the middle section of the small intestine.
• The ileum is the final section of the small intestine.

Definition of Gastrointestinal Intubation

• Gastrointestinal intubation involves inserting a flexible tube through the nose or mouth into the gastrointestinal tract for diagnostic or therapeutic purposes.
• Other Terminology include; nasogastric (NG) tube, orogastric (OG) tube, nasoenteric tube, nasojejunal (NJ) tube.

Clinical Applications

• Used for feeding, medication administration, gastric lavage, specimen collection, and decompression.

Purposes of GI Intubation

• Nutrition.
• Decompression.
• Medication Administration.
• Diagnostic Procedures.

Types of GI Tubes

• Categories include: Nasogastric (NG) Tubes, Orogastric (OG) Tubes, Nasoenteric Tubes, Gastrostomy Tubes (G-tubes), Jejunostomy Tubes (J-tubes), and Gastrojejunostomy Tubes (GJ-tubes).
• Each type serves specific clinical purposes.

Nasogastric Tubes

• A nasogastric tube is a flexible tube inserted through the nose, down the nasopharynx and esophagus into the stomach.
• Pediatric size: 5-8 French.
• Adult size: 10-18 French, with the most common adult size being 12-14 French.
• Materials used include Polyurethane (longer-term use), Silicone (more comfortable), and PVC (short-term use).
• Primary uses include feeding and gastric decompression.

Nasointestinal Tubes

• Nasointestinal tubes are inserted through the nose, past the stomach, into the small intestine.
• They are longer than nasogastric tubes, typically 108-126 inches.
• They are used for post-pyloric feeding and decompression.
• Adult size: 8-12 French.
• Pediatric size: 5-8 French.
• Materials used include Polyurethane (most common), Silicone (reduced irritation), and PVC (less common, shorter-term use).
• Primary uses include enteral feeding when gastric feeding is contraindicated, small bowel decompression, medication administration, and bypassing gastric outlet obstruction.
• Vary from NG, longer length to reach small intestine and smaller diameter.

Orogastric Tubes

• Tubes inserted through the mouth into the stomach.
• Larger in diameter than nasogastric tubes.
• Typically for shorter-term use.
• Associated with less patient discomfort during insertion.
• Reduced risk of sinusitis
• Preferred over nasogastric tubes of patients that have facial trauma or surgery, nasal obstruction or deformity, basilar skull fractures, coagulopathy (bleeding disorders), need for larger diameter tubes, or unconscious patients.

Transabdominal Tubes

• PEG (Percutaneous Endoscopic Gastrostomy) provides direct access to the stomach, used for long-term enteral nutrition, and is placed endoscopically.
• PEJ (Percutaneous Endoscopic Jejunostomy) extends through the stomach into the jejunum, reduces aspiration risk, and bypasses the stomach for absorption issues.
• G-tube (Gastrostomy Tube) is surgically placed into the stomach, can be low-profile ("button"), and is used for medication and nutrition.

Key Clinical Considerations for Transabdominal Tubes.

• Assess for proper placement before use.
• Monitor for infection, leakage, and tube migration.

Percutaneous Endoscopic Gastrostomy (PEG) Tubes

• A PEG tube is placed through the abdominal wall directly into the stomach.
• It provides long-term enteral nutrition access.
• It's used when oral intake is inadequate or unsafe.
• It's an alternative to nasogastric tubes for extended feeding needs.

PEG Tube Placement Procedure

• Endoscope passed through mouth into stomach.
• Transillumination identifies the insertion site.
• Local anesthesia administered to the abdominal wall.
• Small incision made; guidewire inserted.
• Tube pulled through and secured with internal bumper.
• External bumper placed to secure tube position.
• Common indications: Stroke, ALS, head and neck cancer, dementia, prolonged intubation.

Jejunostomy Tubes

• Placed directly into the jejunum.
• Bypasses the stomach completely.
• Are smaller in diameter than gastrostomy tubes.
• Used when gastric feeding is contraindicated.
• Typically placed 15-30 cm distal to the ligament of Treitz.
• Requires careful site care to prevent infection.
• May be temporary or permanent.

Insertion Procedures

• Patient safety is the primary concern.
• Maintain sterile technique at all times.
• Ensure proper patient positioning.
• Use appropriate anatomical landmarks.
• Monitor vital signs throughout the procedure.
• Document all steps and observations.
• Minimize trauma to surrounding tissues.
• Confirm tube placement before use.

Preparation Steps

• Verify patient identity and procedure.
• Obtain informed consent.
• Gather all necessary equipment.
• Perform hand hygiene.
• Don personal protective equipment.
• Prepare the insertion site.
• Position the patient appropriately.
• Administer local anesthetic if indicated.
• Prepare the tube according to manufacturer guidelines.

Nasogastric Tube Insertion Procedure

• Verify the order and patient identity.
• Gather supplies and explain the procedure.
• Position the patient upright (30-45° angle).
• Measure the tube length.
• Mark the tube at the measured distance.
• Lubricate the tip with water-soluble lubricant.
• Insert through the nostril and advance gently.
• Ask the patient to swallow as the tube advances.
• Check placement.
• Secure the tube to the nose with tape.
• Document the procedure and patient response.

Nursing Considerations for NG Tubes

• Assess for contraindications (facial trauma, basilar skull fracture).
• Monitor for respiratory distress during insertion.
• Verify placement before administering anything.
• Check for tube displacement before each use.
• Monitor for complications (aspiration, sinusitis).
• Provide oral care every 4-8 hours.
• Replace the tube according to facility protocol.

Verification of Tube Placement

• Methods include X-ray confirmation and pH testing of aspirate.

X-ray Confirmation

• Gold standard for tube placement verification.
• Confirms exact anatomical position.
• Required for initial placement of all feeding tubes.

Limitations of X-ray Use

• Radiation exposure, cost, not always immediately available.

pH Testing

• Measures acidity of aspirate.
• Gastric aspirate: pH < 5.5.
• Respiratory aspirate: pH > 6.0.
• Intestinal aspirate: pH 6.0-7.0.

Limitations of pH Testing

• Affected by medications (especially acid inhibitors).

Common Errors in Placement Verification

• Air insufflation ("Whoosh Test") is unreliable because sound transmission through tissues can occur even with incorrect placement; false positives in up to 20% of cases.
• Observing bubbling when the tube is placed in water is unreliable.

Tube Maintenance

• Check tube position daily.
• Inspect the insertion site for redness, swelling, or drainage.
• Clean the external portion with mild soap and water.
• Secure the tube properly to prevent dislodgement.
• Monitor for tube blockage.
• Document tube patency and site condition.
• Maintain oral hygiene for NG/OG tubes.
• Verify tube placement before each feeding.

Flushing Protocols

• NG/OG tubes: 30 mL water before/after feedings.
• G-tubes/J-tubes: 20-30 mL water before/after medications.
• Central lines: 5-10 mL saline, followed by heparin per protocol.
• PICC lines: 10 mL saline flush using a pulsatile technique.
• Use lukewarm water for enteral tubes.
• Use sterile technique for all IV access devices.
• Document all flushes in the patient record.

Site Care by Tube Type

• NG/OG tubes: Clean the nostril with saline, apply water-soluble lubricant.
• G-tubes: Clean with mild soap and water in a circular motion, dry completely.
• J-tubes: Gentle cleaning with sterile water; keep dry.
• Central lines: Chlorhexidine swab, sterile dressing change q7 days.
• PICC lines: Sterile technique, transparent dressing, stabilization device.
• Change dressings if soiled or loose.

Enteral Nutrition

• Feeding methods include; Nasogastric (NG) tube, Nasoduodenal tube, Nasojejunal tube, Percutaneous Endoscopic Gastrostomy (PEG), Percutaneous Endoscopic Jejunostomy (PEJ), Gastrostomy tube (G-tube), Jejunostomy tube (J-tube).

Formula Types

• Polymeric (standard), Elemental/semi-elemental, Disease-specific formulas, Modular formulas, Specialized formulas (Renal, Hepatic, Pulmonary, Diabetic, Immunomodulating).

Administration

• Delivery methods: Bolus, Intermittent and Continuous.
• Considerations include; Flow rate, Patient positioning, Residual volume checks, Medication interactions, Tube flushing protocol, Aspiration risk.

Continuous vs. Bolus Feeding

• Continuous feeding is advantageous for reduced risk of aspiration, better tolerance in critically ill patients, more consistent blood glucose levels, a lower incidence of diarrhea, and mimics normal physiological state.

Continuous Feeding Disadvantages

• Requires feeding pump, limited patient mobility, higher cost (equipment), risk of tube clogging, and requires constant monitoring.

Continuous Feeding is Appropriate For.

• ICU patients, patients with high aspiration risk, patients with glucose control issues, post-pyloric feeding, and patients with Gl intolerance.

Bolus Feeding Advantages

• More physiologic gastric distention.
• Allows for mobility between feedings.
• Simpler administration and no pump required.

Bolus Feeding Disadvantages

• Higher risk of aspiration.
• May cause dumping syndrome.
• Glucose fluctuations.
• Potential for diarrhea.
• May cause nausea/bloating.

Bolus Feeding Is Appropriate For

• Stable patients, home care settings, ambulatory patients, patients with normal Gl function, and patients requiring intermittent mobility.

Medication Administration Guidelines

• DO NOT crush extended-release (ER/XR) medications.
• DO NOT crush enteric-coated tablets.
• Use separate mortar and pestle for each medication.
• Crush tablets to a fine powder.
• Mix with an appropriate vehicle (applesauce, pudding).
• Document alternative route in chart.
• Verify with pharmacy when uncertain.

Dilution Requirements

• Follow manufacturer guidelines for dilution.
• Use appropriate diluent (sterile water, NS, D5W).
• Consider osmolarity for IV medications.
• Dilute irritants adequately for patient comfort.
• Calculate final concentration accurately.
• Document dilution ratio in medication record.
• Consider patient fluid restrictions.

Incompatibilities

• Check compatibility before mixing medications.
• Avoid mixing acidic and alkaline solutions.
• Physical incompatibilities: precipitation, color change, gas formation.
• Chemical incompatibilities: degradation, inactivation.
• Use separate IV lines when incompatible.
• Flush lines between incompatible medications.
• Consult pharmacy for compatibility charts.

Decompression Procedures

• Involve connecting to suction.
• Use sterile technique and equipment.

Suction Types

• Intermittent: Cycles between on and off, reduces tissue trauma, and is used for nasogastric tubes.
• Continuous: Constant negative pressure and is used for surgical drains.

Monitoring Output

• Document output and assess characteristics.

Documentation Requirements

• What to document in your clinical notes: Insertion, Verification, Feeding & Output, Client Response.
• Insertion: tube type and size, insertion method used, anatomical placement confirmation, patient tolerance of procedure, any complications encountered.
• Verification: Verification method used, X-ray confirmation (if applicable), pH testing results, visual inspection findings, tube position marking.
• Feeding and Output: formula type and amount, rate and method of administration, residual volumes checked, fluid balance calculations, output measurements.
• Client Response: tolerance to feeding, comfort level during procedure, any adverse reactions, vital signs during/after feeding, patient education provided.

Potential Complications

• Aspiration, tube dislodgement, tube clogging, infection, and GI intolerance.

Case Study: Tube Selection & Care

• Patient: 68-year-old male with COPD exacerbation, admitted with respiratory distress.

Special Considerations

• Pediatric Adaptations: Smaller equipment sizes; lower fluid volumes; weight-based calculations; developmental considerations; Family-centered approach; Distraction techniques.
• Geriatric Concerns: Skin fragility; reduced sensation; Cognitive Assessment; Fall prevention; Medication interactions; slower recovery time.
• Altered Anatomy: stoma care; tracheostomy management; feeding tubes; ostomy appliances; vascular access devices; anatomical landmarks.

Client Education: Tube Care & Home Management

• Daily Care Instructions: Clean the insertion site daily with soap and water, inspect the skin for redness, irritation, or drainage, secure the tube properly to prevent pulling, flush the tube with the prescribed amount of water, maintain proper positioning during and after feedings, store equipment in a clean, dry area, change dressings as instructed.
• Monitoring & Troubleshooting: Check for tube displacement before each use, monitor for signs of infection, watch for tube blockage, document intake and output as instructed, know when to call the healthcare provider.