Gastrointestinal Intubation

Gastrointestinal Intubation

• Gastrointestinal intubation involves placing a tube into the stomach or intestine via the mouth, nose, or abdomen.
• It helps manage GI issues like impaired peristalsis, vomiting, or gas accumulation. It can also be used to provide nutrition.

Learning Objectives

• Define intubation and understand reasons for GI intubation.
• Identify different types of GI tubes.
• List necessary assessments before nasal tube insertion.
• Explain how to perform a nose-to-earlobe-to-xiphoid (NEX) measurement.
• Describe methods for verifying tube placement in the stomach.
• Discuss differences in nasointestinal feeding tube insertion compared to gastric tubes.
• Name schedules for administering tube feedings.
• Explain the importance of assessing gastric residual.
• List nursing actions for caring for tube-fed clients.
• Identify nursing duties for assisting with inserting a weighted intestinal decompression tube.

Gerontologic Considerations

• Reduced laryngeal nerve endings in older adults can diminish the gag reflex.
• Neurologic disorders like dementia, strokes, and Parkinson's can also depress the gag reflex.
• Long-term tube feeding in older adults with dementia raises ethical concerns.
• Refusal to eat in older adults may stem from depression, suicidal thoughts, or cognitive impairment.
• Decisions about nutrition and hydration at the end of life should involve the client (if capable), their medical power of attorney, and the healthcare team. The client's choices must be respected.
• Nurses must stay informed about ethical and legal issues related to tube feedings.
• Tube-feeding formulas should be prescribed according to the older adult's condition (e.g., lactose-free for malabsorption).
• Clients at risk for pressure sores benefit from formulas with added zinc, protein, and other nutrients.
• Registered dietitians can assist with the continuous assessment of tube feedings at home and in long-term care settings.
• Older adults typically tolerate small, continuous feedings better.
• These patients are more prone to fluid and electrolyte imbalances, and hyperglycemia.
• If tube feedings with full-strength formula are administered, capillary blood glucose levels should be regularly monitored until results are within normal range.
• Older adults should be monitored for agitation or confusion, as these can cause inadvertent tube removal.
• Changes in behavior or mental status may be early indicators of fluid or electrolyte imbalances.
• When teaching older adults or their caregivers about G-tube management and tube feedings, allow more time for processing information and provide multiple practice sessions.
• Skilled nursing care may be covered by insurance plans for ongoing teaching and assessments.
• Dietitians can suggest less costly, home-blended formulas for older adults with fixed incomes that meet nutritional needs.

Intubation

• Intubation involves inserting a tube into a body structure.
• Gastrointestinal intubation specifically refers to inserting a tube into the stomach or intestine via the mouth or nose.
• Orogastric intubation means inserting a tube through the mouth into the stomach.
• Nasogastric intubation means inserting a tube through the nose into the stomach.
• Nasointestinal intubation means inserting a tube through the nose into the intestine.
• These procedures are done to remove gas or fluids, or administer liquid nourishment.
• Tubes may also be inserted through surgically created openings (ostomies). The prefix indicates the site of the ostomy, such as gastrostomy for an artificial opening into the stomach.

Types of Tubes

• Gastric and intestinal tubes vary in size, construction, and composition depending on their use.
• Tube size is measured using the French scale; a higher number indicates a larger diameter tube.
• Tubes are identified by their insertion location (mouth, nose, abdomen) and where they terminate (stomach, intestine).

Orogastric Tubes

• Orogastric tubes, such as the Ewald tube, are inserted through the mouth into the stomach.
• These tubes are used in emergencies to remove toxic substances.
• Their large diameter allows removal of pill fragments and stomach debris.

Nasogastric Tubes

• Nasogastric tubes are inserted through the nose and advanced into the stomach.
• These tubes are smaller in diameter than orogastric tubes but larger and shorter than nasointestinal tubes.
• Some nasogastric tubes have multiple lumens (channels).
• A Levin tube is a single-lumen gastric tube that is commonly used for decompression.
• Gastric sump tubes are double-lumen tubes used to remove fluid and gas from the stomach. The second lumen serves as a vent.
• Sump tubes minimize the risk of the stomach wall adhering to and obstructing drainage openings.
• Nasogastric tubes can cause nose and throat discomfort with prolonged insertion.
• Large-diameter tubes or prolonged pressure can irritate or damage nasopharyngeal tissue.
• Gastric tubes may dilate the esophageal sphincter, leading to gastric reflux.
• Gastric reflux increases the risk of liquid entering the airway and interfering with respiratory function.

Nasointestinal Tubes

• Nasointestinal tubes are inserted through the nose for distal placement in the intestine.
• These tubes are longer than their gastric counterparts.
• They provide nourishment (feeding tubes) or remove gas and liquid (decompression tubes).
• Feeding tubes are typically small in diameter, flexible, and made of polyurethane or silicone.

Feeding Tubes

• Nasointestinal feeding tubes, like the Dobhoff tube, are small in diameter and made of a flexible material like polyurethane or silicone.
• The narrow width and soft composition allow them to remain in the same nostril for an extended time.
• They also reduce the potential for gastric reflux by delivering liquid nutrition beyond the stomach.
• Narrow tubes can curl during insertion due to their flexibility.
• Some feeding tubes have a stylet (metal guidewire) and a weighted tip that helps them descend into the stomach. Confirming distal placement can be more difficult.
• Small-diameter tubes are preferred for patient comfort and continuous nourishment.

Intestinal Decompression Tubes

• Intestinal decompression (removal of gas and intestinal contents) can be used if a client has a partial or complete bowel obstruction.
• These tubes feature a double lumen and a weighted tip. One lumen removes intestinal content and the other acts as a vent to reduce suction-induced trauma.

Transabdominal Tubes

• Transabdominal tubes are placed through the abdominal wall and give access to the GI tract.
• This includes the G-tube (gastrostomy tube) which is placed into the stomach, and the J-tube (jejunostomy tube), which is placed into the jejunum of the small intestine.

G-tube Insertion

• A G-tube can be put in place surgically or using an endoscope. A transabdominal tube inserted under endoscopic guidance is called a percutaneous endoscopic gastrostomy (PEG) tube.

Percutaneous Endoscopic Jejunostomy (PEJ) Tube

• A percutaneous endoscopic jejunostomy (PEJ) tube is passed through a PEG tube into the jejunum.
• PEJ tubes usually have a small diameter due to needing to fit within a larger PEG tube. Transabdominal tubes replace can nasogastric/nasointestinal tubes if a patient requires oral feeding for a month or longer.

Nasogastric Tube Management

• Nasogastric tube (NG tube) management includes insertion, maintaining tube patency, implementing its prescribed use, and removing the tube when appropriate.

Nasogastric Tube Insertion

• Nasogastric tube insertion includes preparing the client, pre-intubation assessment, and tube placement.

Client Preparation for NG Tube Insertion

• Clients may experience anxiety prior to NG tube insertion. Explaining the NG tube’s smaller diameter than food pieces and describing the procedure/how the client can assist the process may foster positive client outcomes.
• Providing means for the client to control the situation helps reduce anxiety. A nurse can establish a signal (such as a raised hand) to initiate pausing the tube’s passage.

Preintubation Assessment

• The nurse conducts a focused assessment before insertion including: level of consciousness, weight, bowel sounds, abdominal distension, integrity of nasal/oral mucosa, ability to swallow/cough/gag, and any reported n/v.
• Nurses should perform nasal inspections and check each nostril for size/shape/ patency. Clients should occlude each nostril and exhale. They should also be aware of nasal polyps, deviated nasal septum, /narrow nasal passage as potentially exlcuding the nostril for NG tube insertion.

Nasogastric Tube Measurement

• Some tubes have markings indicating approximate length placing the distal tip in stomach.
• Nurses should perform nose-to-earlobe-to-xiphoid (NEX) measurement and mark the tube.
• First the nurse marks the tube at the measured distance from nose to earlobe: the distance to the nasal pharynx (the tip located in the back of the throat above where the gag reflex is).
• The second mark is where the tube reaches the xiphoid process, indicating the depth needed to reach the stomach.

Nasogastric Tube Placement

• When inserting a nasogastric tube, the priorities are minimizing discomfort, preserving nasal tissue integrity, and locating the tube in the stomach.
• Several methods should be used to assess the abdomen, such as auscultation/instilling air. The pH of aspirated liquid can have a pH less than 5 even with a client taking gastric acid inhibitors.

Nasointestinal Feeding Tube Insertion

• Wash hands or use an alcohol-bases hand rub to prevent microorganism transmission. Wear gloves as physical barrier btw nurse’s hands and body fluids.
• Obtain a flexible small-gague feeding tube including a stylet. These tubes have less potential for traumas and may remain in place longer.

Nasogastric Tubes & Testing pH of Aspirated Fluids

• Evidence indicates testing pH may be unreliable because the PH can be altered by aspirated/swallowed alkaline saliva, gastric secretions, and medications that make gastric secretions less acidic).
• Auscultation over abdomen/instilling air can cause pseudo-confirmatory gurgling. Because of this, the only evidence-based method to determine distal ng tube position are abdominal X-ray/monitoring external tube length.
• Position can also be confirmed using bedside ultrasonography.

Securing NG Tube Post Insertion

• Nurses confirm stomach placement, securing the tube to avoid upward/downward migration.
• Tubes are ready for intended purpose and nurses must verify location within the stomach. Nurses verify distal placement through aspirating fluid from the tube after initial X-ray using 30–50 mL syringe.
• The large volume syringe creates less negative pressure during aspiration to test the pH.
• To begin, insert the tube into nose until it’s reached the second mark. At this point, the tube is presumed to be in the area of the stomach.
• Nurses should also loop the tubing if no respiratory distress is present and tape it temporarily to the cheek.
• Amublating/positioning client on the right side for one hour will help allow the tube to move by gravity throughout the pyloric valve.

Stop, Think, and Respond

• Potential topic of discussion may include potential insertion of the ng tube into the respiratory passages.

Gastric Decompression

• Suction is continuous/intermittent. Continuous suctioning can cause unvented tube to adhere to stomach/cause localized irritation/interfere w/ drainage.
• Using vented tube (or intermittent suction) minimizes these effects. The set up is connected to wall outlet or suction machine (setting prescribed by physician/agency standards.)
• Usually low pressure (40-60 mm HG) is used.

Promoting Patency

• Even with intermittent suctioning, the tube may become obstrcuted, but giving sips of water/ice chips promotes potency.
• The fluid will help dilute gastric secretions (both must be given sparingly to avoid electrolyte imbalance).

Restoring Patency

• The nurse must assess tube potency frequently and monitor drainage, volume, characteristics, observe for sx suggesting obstruction, equipment helps identify causes, etc.
• Sometimes irrigating ng tube is necessary (skill 29-2), but nurse must have physician’s order before attempting.
• Isotonic solutions prevent electrolyte or fluid shifts.

Enteral Nutrition

• Enteral nutrition (nourishment via stomach/intestine, not orally) is delivered by instilling formula through tube.
• Used when patients have intact stomach/intestinal function, but unable to eat/swallow.

Transabdominal Tube Management

• Physician inserts transabdominal tube, but nurse assesses and cares for insertion sites.

Tube Feedings

• Providing nutrition via the oral route is best, but enteral feedings are provided when oral is impossible/jeopardizes client’s safety.
• Tube feedings are used for those with intact stomach/intestinal function, but unconscious, difficult swallowing, gastric/esophageal disorders.

Benefits of Tube Feedings

• Tube feedings deliver through ng/ni and the advantage is that nutritional formula uses body’s natural reservoir for food.
• Reduced for potential enteritis also occur because chemicals in the stomach kill microorganisms (gastric feeding increase risk of gastric reflux—tube placement within intestine reduces risk of gastric reflux.

Nasogastric Tube Advantages/Disadvantages

• Advantages include lower risk of obstruction, ability to administer crushed medications/checking placement is easy. Some of the disadvantages potentially damage nasal/phr mucosa from pressure.
• This can increase risk of aspiration, may need frequent placements to ensure tissue integrity of nasal/ must wait 24 Horus to use, increased incidence of infection, may migrate, and causes gastric overfill

Tube-Feeding Schedules

• Tube feedings administered with bolus feedings, intermittent, continous, cyclic schedules, which is when large amounts delivered over a period of time.
• Intermittent feeding can cause rapid distention of the stomach and the least desirable due to increased reflux risk

Continuous Feedings

• Continuous feedings occur with administration @rate 1.5 ml/minute, a feeding pump is used for regulations, small amount of fluid is instilled, doesn’t need to be held in stomach, delivered directly to small intestine, reduces risk of vomiting and aspirations—pump must go with client.

Client Assessment

• Following daily assessments are standard of EVERY TUBE FEEDING client: weight, fluid intake/output, bowel patterns, lung sounds, ,n/v, temp, breathing pattern, skin, complaints/transabdominal tube, status abdominal distention, bowel, etc.
• The client’s gastric residual is checked determine whether vol/rate exceeds client’s capacity. As a general rule, the residual shouldn’t be higher (100) 20% of the volume of fluid feeding. Otherwise feeding is delayed, if the residual is high, the feeding is topped and hecked again in 30 minutes until safe for feeding to resume).

Nursing Management

• In order to care for clients with feeding tubes, some general areas to look into are the tube patency. Making sure to clear any obstructions, and provide adequent hydration

Maintaining Tube Patency

• In order to maintain tube patency, monitor formula, maintain rate higher than 50 ml/Hour,

Tube-Feeding Problems

• Potential tube-feeding problems include diarrhea, nausea, vomiting, aspirations, constipation, elevated blood glucose level, weight changes, elevated electrolytes, dried or al or nasal mucosa, middle ear inflammation, plugged feeding tube.

Clearing An Obstruction

• One of the possible remedies would be flushing the with to help break up any blockage to help the flow of fluids.
• A product to help with this is the Bionix, which breaks apart blockage and allows for tubing to be cleared with no to little force needed.