3 - GI Tubes & Parenteral Nutrition

• GI intubation involves the insertion of a flexible tube into the stomach, passing the pylorus, and entering the duodenum or jejunum.
• The tube can be inserted through the mouth, nose, or abdominal wall.

Indications for GI Intubation:

• To decompress the stomach and remove gas and fluid.
• To lavage (flush with water or other fluids) the stomach and remove ingested toxins or other harmful materials.
• To diagnose disorders of GI motility and other disorders.
• To administer medications and feedings.
• To compress a bleeding site
• To aspirate gastric contents for analysis.

Tube Types

• Orogastric Tube is a large-bore tube for gastric content removal, inserted through the mouth and mainly used in emergency departments or intensive care units.
• Nasogastric (NG) tube, such as the Sengstaken-Blakemore tube, treats bleeding esophageal varices.

Gastric Tubes

• Levin Tube is a single lumen NGT primarily used for feeding (gastric gavage).
• Salem-Sump Tube is a double-lumen NGT used for decompression, featuring an air vent (blue pigtail) to prevent adherence to the gastric mucosa, with the other lumen connected to low-pressure continuous gastric suction.

Enteric Tubes

• Cantor Tube is a single lumen nasoenteric tube with its balloon inflated with special chemical before insertion.
• Miller-Abbot Tube is a double-lumen nasoenteric tube for decompression, connected to low-pressure gastric suction through the main lumen.

Nursing Management of GI Intubation:

• Prepare the patient.
• Before inserting the tube, determine the necessary length to reach the stomach or small intestine.
• During insertion, instruct the patient to lower their head slightly and swallow as the tube advances upon reaching the nasopharynx.
• After insertion, check the oropharynx to ensure the tube has not coiled in the pharynx or mouth.

Confirming Tube Placement:

• X-ray should initially confirm tube placement
• Measurement of the tube length.
• A visual assessment helps determine aspirate color, where gastric aspirate often appears cloudy and may be green, tan, off-white, or brown, while intestinal aspirate is typically clear and yellow-bile colored.
• The pH measurement of aspirate helps verify placement since gastric aspirate is acidic with a pH of 1 to 5, intestinal aspirate typically has a pH of 6 or higher, and respiratory aspirate is more alkaline with a pH of 7 or greater.

Tube Obstruction Clearance:

• Use air insufflation.
• Inject 20 mL of air and pull back the plunger; if not effective, repeat or notify a physician.
• Infuse digestive enzymes

Maintaining Tube Function:

• For decompression, connect the tube to suction or a collection bag.
• Plug the end of the tube between feedings for enteral nutrition.
• Be aware that tension, coughing, suctioning, or intubation can displace the tube.
• Keep accurate records of fluid intake, feedings, and irrigation.
• For patency, irrigate the tube with water or normal saline every 4 to 6 hours.
• Record the amount, color, and type of drainage every 4 to 8 hours.
• When using double-lumen or triple-lumen tubes: label each lumen for its intended use, aspiration or feeding.

Hygiene and Complications:

• Ensure oral and nasal hygiene.
• Inspect the nose daily for skin irritation.
• Change the nasal tape every 2 to 3 days.
• Inhalations of steam or cool vapor can help with dry nasal and pharyngeal mucosa.
• Sucking on throat lozenges, using an ice collar, chewing gum, or hard candies (if permitted) may relieve patient discomfort.
• Monitor for potential complications like fluid volume deficit, pulmonary complications, or tube-related irritations.

Tube Removal:

• Before taking out a decompression tube intermittently clamp it for several hours to ensure no nausea, vomiting, or distention occurs.
• Before taking out any tube, flush it with 10 mL of water or normal saline to ensure its free of debris away from the stomach lining.
• Gently and slowly withdraw the tube for 15 to 20 cm (6 to 8 inches) until the tip is at the esophagus; then rapidly pull the remainder out of the nostril.
• Avoid forcing the tube if removal is difficult, and consult is needed report the problem to the physician.
• Conceal the tube in a towel during withdrawal to prevent secretions from soiling the patient or nurse.
• Provide oral hygiene immediately after removal.

Tube Feeding Administration:

• Rapid water movement to the stomach and intestines from fluid surrounding the organs and the vascular compartment can occur with concentrated solutions of high osmolality are taken in large amounts.
• The patient may experience fullness, nausea, and diarrhea, collectively termed dumping syndrome; it can cause dehydration, hypotension, and tachycardia.

Preventing Dumping Syndrome:

• Reduce the formula instillation rate to allow time for carbohydrates and electrolytes to dilute.
• Administer feedings at room temperature to avoid stimulating peristalsis.
• Administer feeding by continuous drip (if tolerated) to prevent sudden intestinal distention.
• Position the patient in semi-Fowler's position for 1 hour after the feeding for prolonged intestinal transit time.
• Instill the minimal water amount needed to flush the tubing before and after feeding.

Methods for Administering Formula:

• Bolus Feeding is delivered by gravity into the stomach (usually via gastrostomy tube) through a large syringe, where feedings of 300 to 500 mL take 10 to 15 minutes to complete. Intermittent Gravity Drip Feeding Method involves administering feedings for 30 minutes at set intervals using a reservoir enteral bag and tubing. This method is often used at home.
• Continuous Feeding: delivery of feedings incrementally given over long periods of time.
• Cyclic Feeding: infused feeding given over 8 to 18 hours and may be infused at night so it doesn't interrupt the patient's lifestyle.

Equipment and Nutritional Balance:

• Monitor the drip rate to prevent rapid fluid administration.
• Measure residual gastric volumes ahead of each intermittent feeding and every 4 to 8 hours with continuous feedings, also re-administer aspirated fluid to the patient.
• Continue tube feedings in patients with gastric residual volumes over 200 mL as long as there is close monitoring of the patient's trends, study results, and physical status.
• When excessive residual volumes (more than 200 mL) occur twice, inform the physician.
• Flush with at least 30 to 50 mL of water or normal saline to maintain patency and decrease bacterial growth or tube occlusion. This occurs before/after each dose of medication and tube feeding, after checking gastric residuals and pH, every 4-6 hours with continuous feedings, when tube feedings are discontinued/interrupted, and when the tube is not in use, with a recommendation of flushing twice daily.
• Keep track of any water or normal saline used to irrigate.

Types of Feeding Delivery Systems:

• Open System: packaged as a liquid or powder to be mixed with water.
• Closed Delivery System: uses a pre-filled, sterile container spiked with enteral tubing.

Risk of Aspiration Pneumonia:

• Occurs when regurgitation causes stomach contents or enteral feedings from an improperly placed feeding tube to enter the pharynx or trachea.
• May also occur due to aspirated oral secretions.

Gastrostomy & Jejunostomy

• This is a surgical procedure: an opening is created in the stomach for food/fluid administration or gastric decompression for intestinal obstruction.
• Indications include delivering prolonged enteral nutritional support (longer than four weeks) and the patient's comatose state (makes regurgitation and aspiration less likely than with NG feedings).
• A jejunostomy is similarly placed yet extends beyond the pylorus into the jejunum.

Percutaneous Endoscopic Gastrostomy (PEG)

• It should fit to prevent leaks of gastric secretions.
• It should be maintained in place.
• It should have gentle traction between devices.
• LPGDs may be inserted 3 to 6 months after initial placement.

Nursing Diagnoses:

• Acute pain
• Risk for infection related to wound and tube presence
• Risk for impaired skin integrity at tube insertion site
• Disturbed body image related to tube presence

Potential Complications:

• Wound infection, cellulitis, and leakage
• GI bleeding
• Premature tube dislodgement

Nursing Measures:

• Offer nourishment soon after insertion, which can consist of tap water, normal saline, or 10% dextrose, followed by formula feeding beginning on the second day if there are no fluid leaks around the tube and the patient can tolerate it.
• Employ thin gauze dressing between the tube insertion site and the gastrostomy tube.
• Ensure regular verification of the tube's placement (measuring pH of aspirate) and gentle manipulation/stabilizing of the disk to avoid skin breakdown in the area
• If the tube drains stomach contents because of a GI obstruction: connect it to low, intermittent suction or a gravity drainage bag.
• Provide skin care and enhance body Image.
• Look at the surgical site for wounds or cellulitis.
• Looking for bleeding and dislodgement.

Parenteral Nutrition:

• It is a method of providing nutrients to the body through an IV route, aiming to improve nutritional status, establish a positive nitrogen balance, maintain muscle mass, promote weight maintenance/gain, and enhance the healing process.
• It is used when oral food/fluids are inadequate, there is insufficient or impaired oral/enteral intake, the patient is unwilling or unable to ingest nutrients orally/enterally, or when nutritional needs are prolonged pre- or post-operatively. A total of 1 to 3 L of solution is administered over a 24-hour period. Intravenous fat emulsions (IVFEs) may be simultaneously infused without filtering through a Y-connector. Typically, 500 mL of a 10% IVFE or 250mL of 20% IVFE is administered over 6 to 12 hours, one to three times a week.
• An initial therapy involves slowly increasing the rate each day as tolerated by the patient's fluid and dextrose. Standard orders include regular monitoring of weight, I&O, levels of blood glucose, and periodic and baseline testing of CBC, platelet count, and chemistry panel (including serum CO2, P, Mg, and triglycerides). A 24-hour urine nitrogen should be determined for analysis of nitrogen balance.,
• Solution is less hypertonic than a full calorie parenteral nutrition solution. With low dextrose content. Lipids are administered simultaneously to buffer the PPN and to protect the peripheral vein from irritations. . The usual length of therapy is 5 to 7 days. Administration by central method have 5 or 6 times the solute concentration of blood and administered into the vascular system through the catheter inserted into a high-flow, large blood vessel. Types : non-tunneled/ peripheral/ tunneled and implanted.
• When stopping PN, gradually decrease its levels to let the patient adjust to decreasing levels of glucose and administer isotonic dextrose for 1–2 hours if terminated immediately.
• Once IV therapy is complete, remove the nontunneled venous catheter or PICC. For the occlusive dressing, the exit site for the catheter is where you apply it and for tunneled catheters and implanted ports, they can only be removed by the physician.

Nursing Diagnoses for Parenteral Nutrition Include:

• Imbalanced nutrition: is less than body because the requirements are not enough for body in oral nutrients.
• Risk for infection: contamination of the central catheter site or it needs infusion for fluid intake.
• Risk for imbalanced fluid volume: r/t the infusion is not good enough to sustain fluid in the body.
• There is a problem with Anxiety: the site needs a tube that does not help with care.

Potential Complications:

• Pneumothorax
• Air embolism
• A clotted or displaced catheter
• Sepsis
• Hyperglycemia
• Rebound hypoglycemia
• Fluid overload

Nursing Action :

• Always maintain optimal nutrition.
• Prevent infection and maintain fluid balance.
• Promote activity.