GASTROINTESTINAL SYSTEM PROCEDURES

PYRAMID POINTS Common types of tubes used in the clinical setting Assessment points related to the specific type of tube Procedures for insertion of a particular tube Standard (universal) precautions Handling infectious materials

PYRAMID POINTS Verifying correct placement and procedures for administering medications or feedings, if appropriate Interventions related to the care of the client Interventions associated with complications or emergencies that may occur Client/family education regarding care at home

NASOGASTRIC (NG) TUBES DESCRIPTION Short tubes used to intubate the stomach Inserted from the nose to the stomach

NASOGASTRIC (NG) TUBES LEVINE Single-lumen nasogastric tube Used to remove gastric contents via intermittent suction or to provide tube feedings

LEVINE TUBE From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.

NASOGASTRIC (NG) TUBES SALEM SUMP Double-lumen nasogastric tube with an air vent Used for decompression with continuous suction Air vent is not to be clamped and is to be kept above the level of the stomach If leakage occurs through the air vent, instill 30 ml of air into the air vent and irrigate the main lumen with normal saline (NS)

SALEM SUMP TUBE From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.

NG TUBE INTUBATION PROCEDURES Place the client in high-Fowler’s position Measure from tip of nose to earlobe to xiphoid process to determine the length of insertion and mark with tape Lubricate tube about 3 inches with a water-soluble jelly only (oil-soluble is not used), to prevent the development of pneumonia if the tube accidentally slips into the bronchus Instruct the client to bend the head forward, which closes the epiglottis and opens the esophagus

NG TUBE INTUBATION PROCEDURES Insert into nostril, advance backward and through the nasopharynx Have the client take a sip of water and advance tube as the client swallows Do not force the tube If the client experiences any respiratory distress (coughing or choking) during insertion, pull back on the tube and wait until the distress subsides

NG TUBE INTUBATION PROCEDURES Advance until taped mark is reached; tape in place when correct placement is confirmed If feedings are prescribed, x-ray confirmation should be done prior to initiating feedings When gastrointestinal (GI) tubes are attached to suction, suction may be continuous or intermittent, with a pressure not exceeding 25 mmHg as prescribed by the physician

TECHNIQUE FOR MEASURING THE DISTANCE TO INSERT THE NG TUBE From Perry, A. & Potter, P. (2002). Clinical nursing skills and techniques, ed 5, St Louis: Mosby.

ASSESSING NG TUBE PLACEMENT The most reliable method to determine placement is by x-ray Assess placement every 4 hours and before administering feedings or medications Assess placement by aspirating gastric contents and measuring the pH, which should be 4 or less (pH values greater than 6 indicate intestinal placement) Inserting 5 to 10 ml of air into the NG tube and listening for the rush of air over the stomach with a stethoscope is an alternative method for assessing placement, but is not as reliable as an x-ray or checking gastric pH

ASSESSING RESIDUAL VOLUMES Check residual volumes every 4 hours, before each feeding, and before giving medications Aspirate all stomach contents (residual) and measure amount Reinstill residual feeding to prevent excessive fluid and electrolyte losses unless the residual volume appears abnormal

IRRIGATING A NG TUBE Performed every 4 hours to check the patency of the tube Assess placement before irrigating Gently instill 30 to 50 ml of water or normal saline (NS) (depending on agency policy) with an irrigation syringe Pull back on the syringe plunger to withdraw the fluid to check patency; repeat if tube remains sluggish

REMOVAL OF AN NG TUBE Ask the client to take a deep breath and hold Remove the tube slowly and evenly over the course of 3 to 6 seconds (coil the tube around the hand as it is being removed)

GI TUBE FEEDINGS TUBES Nasogastric Nasoduodenal or nasojejunal Gastrostomy Jejunostomy

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) TUBE From Perry, A. & Potter, P. (2002). Clinical nursing skills and techniques, ed 5, St Louis: Mosby.

ENDOSCOPIC INSERTION OF JEJUNOSTOMY TUBE From Perry, A. & Potter, P. (2002). Clinical nursing skills and techniques, ed 5, St Louis: Mosby.

GI TUBE FEEDINGS TYPES OF FEEDINGS Bolus Continuous Cyclical

GI TUBE FEEDINGS BOLUS Resembles normal meal feeding patterns Can be administered via a syringe or via an intermittent feeding With an intermittent feeding, approximately 300 to 400 ml of formula is administered over a 30- to 60-minute period every 3 to 6 hours

SYRINGE FEEDING From Perry, A. & Potter, P. (2002). Clinical nursing skills and techniques, ed 5, St Louis: Mosby.

GI TUBE FEEDINGS CONTINUOUS Administered continuously for 24 hours An infusion pump regulates the flow CYCLICAL Administered either in the daytime or nighttime for 8 to 16 hours Feedings at night allow for more freedom during the day

CONTINUOUS FEEDING From Perry, A. & Potter, P. (2002). Clinical nursing skills and techniques, ed 5, St Louis: Mosby.

ADMINISTERING GI TUBE FEEDINGS Position the client in high-Fowler’s and on the right side if comatose Warm feeding to room temperature to prevent diarrhea and cramps Aspirate all stomach contents (residual), measure the amount, and return the contents to the stomach to prevent electrolyte imbalances Check physician’s order and agency policy regarding residual amounts; usually if the residual is less than 100 to 150 ml, feeding is administered; if greater than 150 ml, hold the feeding

ADMINISTERING GI TUBE FEEDINGS Assess tube placement by aspirating gastric contents and measuring the pH (should be 4 or less) Assess bowel sounds; hold feeding and notify the physician if bowel sounds are absent Use a feeding pump for continuous or cyclical feedings For bolus feeding, leave the client in a high-Fowler’s position for 30 minutes after feeding For a continuous or cyclical feedings, keep the client in a semi-Fowler’s position at all times

PRECAUTIONS: GI TUBE FEEDINGS Change the feeding container and tubing every 24 hours Do not hang more solution than will be required for a 4-hour period to prevent bacterial growth Check the expiration date on the formula prior to administering Shake the formula well prior to inserting into container

PRECAUTIONS: GI TUBE FEEDINGS Always assess placement of the tube prior to feeding Always assess bowel sounds; do not administer any feedings if bowel sounds are absent If an obstruction occurs, try flushing with water, saline, cranberry juice, ginger ale, or cola, if not contraindicated, after checking placement

PRECAUTIONS: GI TUBE FEEDINGS Add a drop of methyline blue to the feeding, particularly with clients who have endotracheal or tracheal tubes; suspect tracheoesophageal fistula when blue gastric contents appear in tracheal excretion and if this is noted, notify the physician immediately Administer feeding at prescribed rate, or via gravity flow (intermittent, bolus feedings) with a 60-ml syringe with the plunger removed Gently flush with 30 to 50 ml of water or normal saline (depending on agency policy) with the irrigation syringe after the feeding

COMPLICATIONS OF NG TUBE FEEDINGS Aspiration Vomiting Diarrhea Clogged tube

PREVENTING ASPIRATION Verify tube placement Do not administer feeding if residual is greater than 150 ml Keep the head of the bed elevated If aspiration occurs, suction as needed, assess respiratory rate, auscultate lung sounds, monitor temperature for aspiration pneumonia, and prepare to obtain chest radiograph

PREVENTING VOMITING Administer feedings slowly, and for bolus feedings, make the feeding last for 30 minutes Do not allow feeding to run dry Do not allow air to enter the tubing Administer feeding at room temperature Elevate the head of the bed Administer antiemetics as prescribed If client vomits, place in side-lying position

PREVENTING DIARRHEA Use fiber-containing feedings Administer feeding slowly and at room temperature

PREVENTING A CLOGGED TUBE Use liquid forms of medication, if possible Flush the tube with 30 to 50 ml of water or NS (depending on agency policy) before and after medication administration and before and after bolus feeding Flush with water every 4 hours for continuous feeding

MEDICATIONS VIA A GI TUBE Crush medications or use elixir forms of medications; assure that the medication ordered can be crushed or that the capsule can be opened Dissolve crushed medication or capsule contents in 5 to 10 ml of water Check placement and residual prior to instilling medications

MEDICATIONS VIA A GI TUBE Draw up the medication into a catheter tip syringe, clear excess air, and insert medication into the tube Flush with 30 to 50 ml of water or NS (depending on agency policy) Clamp the tube for 30 to 60 minutes (depending on medication and agency policy)

INTESTINAL TUBES DESCRIPTION Passed nasally into the small intestine Used to decompress the bowel or to remove intestinal contents Enters the small intestine through the pyloric sphincter because of the weight of a small bag of mercury at the end

TYPES OF INTESTINAL TUBES Cantor and Harris tube Miller-Abbott tube

CANTOR AND HARRIS TUBE Single-lumen tube with a reservoir for 5 to 10 ml of mercury located at its tip, below the level of the drainage holes Mercury is inserted before the tube is passed through the nose, making the procedure uncomfortable The Harris tube is also used for lavage and suction

CANTOR TUBE From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.

MILLER-ABBOTT TUBE A double-lumen tube One lumen is for the instillation of mercury once the tube is in the stomach, and the other is for irrigation or drainage

MILLER-ABBOTT TUBE From Monahan, F. & Neighbors, M. (1998) Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.

INTESTINAL TUBES IMPLEMENTATION Assess physician’s orders and agency policy for advancement and removal of tube Position client on the right side to facilitate passage of the mercury weights within the tube through the pylorus of the stomach and into the small intestine Do not secure the tube to the face with tape until it has reached final placement (may take several hours) in the intestines X-ray is performed to verify desired placement

INTESTINAL TUBES IMPLEMENTATION Monitor drainage from the tube If the tube becomes blocked, notify the physician; a small amount of air injected into the lumen may be prescribed to clear the tube Assess the abdomen and measure abdominal girth

INTESTINAL TUBES IMPLEMENTATION To remove the tube, the mercury and air are removed from the balloon portion of the tube with a 5-ml syringe; the tube is gradually removed (6 inches every hour) as prescribed by the physician Dispose the mercury in the appropriate manner as per agency policy

ESOPHAGEAL AND GASTRIC TUBES DESCRIPTION Used to apply pressure against esophageal veins to control bleeding Not used if the client has ulceration or necrosis of the esophagus or had previous esophageal surgery

ESOPHAGEAL AND GASTRIC TUBES TYPES Sengstaken-Blakemore tube Minnesota tube

SENGSTAKEN-BLAKEMORE TUBE Triple-lumen gastric tube with an inflatable esophageal balloon, an inflatable gastric balloon, and a gastric aspiration lumen The gastric balloon applies pressure at the cardioesophageal junction to directly compress gastric varices and to decrease blood flow to esophageal varices; traction is applied to maintain the gastric balloon in place The esophageal balloon directly compresses esophageal varices

SENGSTAKEN-BLAKEMORE TUBE If bleeding is not stopped with inflation of the gastric balloon, the esophageal balloon is inflated to 25 to 45 mmHg An x-ray of upper abdomen and chest confirms placement Gastric contents are aspirated by gastric lavage or intermittent suction via the gastric aspiration port A nasogastric tube is also inserted in the opposite naris to collect secretions that accumulate above the esophageal balloon

SENGSTAKEN-BLAKEMORE TUBE From Monahan, F. & Neighbors, M. (1998), Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.

MINNESOTA TUBE Four-lumen gastric tube A modified Sengstaken-Blakemore tube with an additional lumen for aspirating esophagopharyngeal secretions

ESOPHAGEAL AND GASTRIC TUBES IMPLEMENTATION Check patency and integrity of all balloons prior to insertion Label each lumen Place the client in the upright or Fowler’s position for insertion Prepare for x-ray immediately after insertion to verify placement Maintain head elevation once the tube is in place

ESOPHAGEAL AND GASTRIC TUBES IMPLEMENTATION Double-clamp the balloon ports to prevent air leaks Keep scissors at the bedside at all times; monitor for respiratory distress and if it occurs, cut tubes to deflate balloons Release esophageal pressure as prescribed and per agency policy to prevent ulceration or necrosis of the esophagus

ESOPHAGEAL AND GASTRIC TUBES IMPLEMENTATION Monitor for increased bloody drainage, which may indicate persistent bleeding Monitor for signs of esophageal rupture, which includes a drop in blood pressure, increased heart rate, or back and upper abdominal pain Esophageal rupture is an emergency and must be reported to the physician immediately

LAVAGE TUBES DESCRIPTION Used to remove toxic substances from the stomach

LAVAGE TUBES LAVACUATOR An orogastric tube with a large suction lumen and a smaller lavage/vent lumen that provides continuous suction Irrigation solution enters the lavage lumen while stomach contents are removed through the suction lumen EWALD’S Reusable single-lumen large tube used for rapid one-time irrigation and evacuation

LAVACUATOR TUBE From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.