GI Tubes & Parenteral Nutrition PDF

GASTROINTESTINAL INTUBATION GI Intubation - the insertion of a flexible tube into the stomach, beyond the pylorus into the duodenum or the jejunum - the tube may be inserted through the mouth, the nose, or the abdominal wall. Indications: To decompress the stomach and remove gas and fluid...

GASTROINTESTINAL INTUBATION GI Intubation - the insertion of a flexible tube into the stomach, beyond the pylorus into the duodenum or the jejunum - the tube may be inserted through the mouth, the nose, or the abdominal wall. Indications: 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 - a large-bore tube inserted through the mouth with a wide outlet for removal of gastric contents; used primarily in the emergency department or an intensive care setting. Nasogastric (NG) Tube such as the Sengstaken-Blakemore tube is used to treat bleeding esophageal varices  Gastric Tubes Levin Tube - a single lumen NGT that is primarily used for feeding (gastric gavage) Salem - Sump Tube - a double-lumen NGT used for decompression. The air vent (blue pigtail) prevents adherence of the tube to the gastric mucosa. The other lumen is to the connected to low pressure continuous to gastric suction.  Enteric Tubes Cantor Tube - a single lumen nasoenteric tube with its balloon inflated with special chemical before insertion. Miller-Abbot Tube - a double-lumen nasoenteric tube used for decompression. The main lumen is connected to a low pressure gastric suction. Nursing Management 1. Prepare the patient. 2. Insert the tube. a. Before: Determine the length that will be needed to reach the stomach or the small intestine, b. During: When the tube reaches the nasopharynx, instruct the patient to lower the head slightly and to begin to swallow as the tube is advanced c. After: Inspect the oropharynx to ensure that the tube has not coiled in the pharynx or mouth. 3. Confirm the placement. a. Initially: X-ray should be used to confirm tube placement b. Measurement of the tube length c. Visual assessment of aspirate color: Gastric aspirate is most frequently cloudy and green, tan, off-white, or brown. Intestinal aspirate is primarily clear and yellow to bile colored. d. pH measurement of aspirate i. Gastric aspirate is acidic (1 to 5) ii. Intestinal aspirate is typically 6 or higher iii. Respiratory aspirate is more alkaline (7 or greater). e. Air auscultation 4. Clear tube obstruction a. Air Insufflation b. Inject 20 mL of air, pull plunger back (if ineffective, repeat the procedure); if unsuccessful notify the physician. c. Infusion of digestive enzyme 5. Monitor the patient and maintaining tube function a. For decompression: connect to suction or a collection bag. b. For enteral nutrition: plug end of the tube between feedings. c. Displacement of tube may be caused by tension on the tube with patient movement, coughing, suctioning, or airway intubation. d. Keep an accurate record of all fluid intake, feedings, & irrigation. e. To maintain patency: irrigate tube every 4 to 6 hrs with water or NS. f. Record the amount, color, and type of any drainage every 4 to 8 hours. g. When double-lumen or triple-lumen tubes are used: label each lumen according to its intended use for aspiration or feeding. 6. Provide oral and nasal hygiene. a. Inspect the nose daily for skin irritation. b. Change the nasal tape every 2 to 3 days. c. For dry nasal and pharyngeal mucosa: steam or cool vapor inhalations. d. Throat lozenges, an ice collar, chewing gum, or sucking on hard candies (if permitted) and limiting talking also assist in relieving patient discomfort. 7. Monitor and managing potential complications: a. fluid volume deficit b. pulmonary complications c. tube-related irritations Tube Removal 1. Before removing a decompression tube: intermittently clamp it for a trial period of several hours to ensure that the patient does not experience nausea, vomiting, or distention. 2. Before any tube is removed: flush it with 10 mL of water or normal saline to ensure that it is free of debris and away from the gastric lining. 3. Withdraw the tube gently and slowly for 15 to 20 cm (6 to 8 in) until the tip reaches the esophagus; the remainder is withdrawn rapidly from the nostril. 4. If the tube does not come out easily, force should not be used, and the problem should be reported to the physician. 5. As the tube is withdrawn, conceal the tube in a towel to prevent secretions from soiling the patient or nurse. 6. Provide oral hygiene after the tube is removed. Administration of Tube Feedings - When a concentrated solution of high osmolality is taken in large amounts, water moves rapidly to the stomach and intestines from fluid surrounding the organs and the vascular compartment. - The patient has a feeling of fullness, nausea, and diarrhea; this can cause dehydration, hypotension, and tachycardia, collectively termed dumping syndrome. How to Prevent? 1. Slow the formula instillation rate to provide time for carbohydrates and electrolytes to be diluted. 2. Administer feedings at room temperature, because temperature extremes stimulate peristalsis. 3. Administer feeding by continuous drip (if tolerated) rather than by bolus, to prevent sudden distention of the intestine. 4. Advise the patient to remain in semi-Fowler’s position for 1 hour after the feeding; this position prolongs intestinal transit time by decreasing the effect of gravity. 5. Instill the minimal amount of water needed to flush the tubing before and after a feeding, because fluid given with a feeding increases intestinal transit time. Administration Methods: 1. Bolus Feeding - administered by gravity into the stomach (usually by gastrostomy tube) through a large syringe; feedings of 300 to 500 mL require 10 to 15 minutes to complete. 2. Intermittent Gravity Drip Feeding Method - requires administering feedings over 30 minutes at designated intervals by a reservoir enteral bag and tubing; commonly used when the patient is at home. Administration Methods: 3. Continuous Feeding - delivery of feedings incrementally over long periods. 3. Cyclic Feeding - infused feeding is given over 8 to 18 hours. Feedings may be infused at night to avoid interrupting the patient’s lifestyle. Maintain feeding equipment & nutritional balance: 1. Monitor the drip rate and avoid administering fluids too rapidly. 2. Residual gastric volumes: a. Measure before each intermittent feeding and every 4 to 8 hours during continuous feedings. b. Re-administer aspirated fluid to the patient. c. Continue tube feedings in patients with gastric residual volumes that exceed 200 mL as long as there is close monitoring of gastric residual volume trends, x-ray study results, and the patient’s physical status. d. If excessive residual volumes (more than 200 mL) occur twice, notify the physician. 3. To ensure patency & to decrease the chance of bacterial growth, crusting, or occlusion of the tube, at least 30 to 50 mL of water or normal saline is administered in each of the following instances: a. Before and after each dose of medication and tube feeding b. After checking for gastric residuals and gastric pH c. Every 4 to 6 hours with continuous feedings d. If the tube feeding is discontinued or interrupted for any reason e. When the tube is not being used, where a minimum of twice-daily flushing is recommended f. Any water or normal saline used to irrigate these tubes must be recorded as fluid intake  Feeding Delivery Systems 1. Open System - packaged as a liquid or as a powder to be mixed with water 2. Closed Delivery System - uses a pre- filled, sterile container that is spiked with enteral tubing Risk for Aspiration Pneumonia - occurs when regurgitated stomach contents or enteral feedings from an improperly positioned feeding tube are instilled into the pharynx or the trachea or when oral secretions are aspirated. GASTROSTOMY & JEJUNOSTOMY This is a surgical procedure in which an opening is created into the stomach for the purpose of administering foods and fluids via a feeding tube or for gastric decompression in the setting of intestinal obstruction. Indications: to deliver enteral nutritional support longer than 4 weeks patient who is comatose (making regurgitation and aspiration less likely than with NG feedings) A jejunostomy is similarly placed, but the distal end extends beyond the pylorus into the jejunum.  Percutaneous Endoscopic Gastrostomy (PEG) This should be fitted securely to the stoma to prevent leakage of gastric secretions and is maintained in place through gentle traction between the internal and anchoring devices. An alternative to the PEG device is a low-profile gastrostomy device (LPGD). LPGDs may be inserted 3 to 6 months after initial gastrostomy tube placement. Nursing Diagnosis: 1. Acute pain 2. Risk for infection related to presence of wound and tube 3. Risk for impaired skin integrity at tube insertion site 4. Disturbed body image related to presence of tube Potential Complications: 1. Wound infection, cellulitis, and leakage 1. GI bleeding 1. Premature dislodgement of the tube Nursing Interventions: Meet Nutritional Needs Administer first fluid nourishment soon after tube insertion and can consist of tap water, normal saline, or 10% dextrose. By the second day: formula feeding may begin, provided it is tolerated and no fluid leaks from around the tube. Provide Tube Care and Prevent Infection Apply a thin gauze dressing between the tube insertion site and the gastrostomy tube. Verify the tube’s placement (pH measurement of aspirate) and gently manipulate the tube or stabilize disk once daily to prevent skin breakdown. If the tube has been placed to drain the stomach contents because of a GI obstruction: connect it to either low, intermittent suction or to a gravity drainage bag.  Provide Skin Care Enhance Body Image Monitoring & Managing Potential Complications: ○ Wound infection or cellulitis at the exit site ○ Bleeding ○ Dislodgement PARENTERAL NUTRITION Parenteral Nutrition (PN) - a method of providing nutrients to body by an IV route. - goals: - improve nutritional status - establish a positive nitrogen balance - maintain muscle mass - promote weight maintenance or gain - enhance the healing process. Clinical Indications: inability to ingest adequate oral food or fluids within 7 days insufficient or impaired oral or enteral intake patient is unwilling or unable to ingest adequate nutrients orally or enterally preoperative and postoperative nutritional needs are prolonged Formulas: A total of 1 to 3 L of solution is administered over a 24- hour period. Intravenous fat emulsions (IVFEs) may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered. Usually 500 mL of a 10% IVFE or 250 mL of 20% IVFE is administered over 6 to 12 hours, one to three times a week. Initiate Therapy - slowly and advanced gradually each day to the desired rate as the patient’s fluid and dextrose tolerance permits. - Standard Orders: - weigh the patient - monitor I&O, and blood glucose - baseline and periodic monitoring of CBC, platelet count, and chemistry panel, including serum CO2, Mg, P, and triglycerides. - determine a 24-hour urine nitrogen for analysis of nitrogen balance. Administration: Peripheral Method - administered through a peripheral vein. - 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 irritation. - The usual length of therapy is 5 to 7 days. Administration: Central Method have 5 or 6x the solute concentration of blood Administered into the vascular system through a catheter inserted into a high-flow, large blood vessel Types: ○ Nontunneled CC = less than 6 wks IV therapy ○ Peripherally-Inserted CC = several days to months ○ Tunneled CC = long-term (years) ○ Implanted Ports = long-term w/ freedom in ADL How to Discontinue PN? - Gradually to allow the patient to adjust to decreased levels of glucose. - If the PN solution is abruptly terminated, administer isotonic dextrose for 1 to 2 hours to prevent rebound hypoglycemia. - Once all IV therapy is completed: remove the nontunneled central venous catheter or PICC and apply an occlusive dressing to the exit site (tunneled catheters and implanted ports are removed only by the physician). Nursing Diagnosis: 1. Imbalanced nutrition: less than body requirements r/t inadequate oral intake of nutrients 2. Risk for infection r/t contamination of the central catheter site or infusion line 3. Risk for imbalanced fluid volume r/t altered infusion rate 4. Anxiety r/t catheter care and securement Potential Complications: 1. Pneumothorax 2. Air embolism 3. A clotted or displaced catheter 4. Sepsis 5. Hyperglycemia 6. Rebound hypoglycemia 7. Fluid overload Nursing Interventions: 1. Maintain optimal nutrition 2. Prevent infection 3. Maintain fluid balance 4. Encourage activity