1. 4/28/2017
Nasogastric Tubes
NUR 171
Relief!!!!

2. Nasogastric (NG) Tube From Naso (nose) Into gastric (Stomach).
4/28/2017
Nasogastric (NG) Tube
From Naso (nose)
Into gastric (Stomach).

3. Two Purposes Removal of Gastric Contents
4/28/2017
Two Purposes
Removal of Gastric Contents
decompression
Introduction of Nutrients into the stomach
AKA: Enteral Feeding
Medications
Irrigation
Stomach decompression or rest: pancreatitis, cholecyctitis with refractory N/V
Bowel decompression or to rest the bowel:
Some indications: small bowel obstruction (SBO), diverticulitis, ulcerative colitis, crohns flareup
You will be learning about these problems in a few weeks
Enteral feeds used a different type of tube that is designed for feeding.
Please review Block 1 material regarding enteral feedings.
We will be focusing only on decompression of the stomach in Bock 2

4. NG Tubes: Decompression
4/28/2017
NG Tubes: Decompression
LevinTube - one lumen
To instill material into stomach
To suction material out of the stomach
Salem Sump Tube - two lumens
blue pigtail (air vent)
most common
used for decompression.
Levin Tube. The Levin tube is a one-lumen plastic nasogastric tube with several drainage holes near the gastric end of the tube.
There are graduated markings on the lumen to determine how far the tube is inserted into the patient.
Advantages /inserted either nasally or orally and that it is firm enough to be passed into an unconscious patient
flexible enough so there is little danger of producing injury. T
chief danger in passing this tube is the possibility of it entering the trachea rather than the esophagus. Care must also be taken to avoid injury to the mucous membrane
Disadvantage: not good for continuous suctioning can adhere to the gastric wall and cause injury.
The Salem-Sump Tube. Ventrol It has a drainage lumen and a smaller secondary tube that is open to the atmosphere (air vent). The major advantage of this two-lumen tube is that it can be used for continuous suction
Advantage:The continuous airflow reduces the frequency of stomach contents being drawn up into the whole of the lumen which is in the patient's stomach.
Disadvantage: chief danger in passing this tube is the possibility of it entering the trachea rather than the esophagus. Care must also be taken to avoid injury to the mucous membrane

5. NG tubes Decompression
4/28/2017
NG tubes Decompression
Miller-Abbott
double lumen
passes through the pylorus into the duodenum
Balloon inflated and moves through the intestine by peristalsis
The Miller-Abbott Tube. This tube is also a two-lumen nasogastric tube. There is a rubber balloon at the tip of one tube; the other tube has holes near its tip. Used for intestinal obstruction and for diagnostic studies and irrigation of the small intestine.
After one tube has passed through the pylorus (the opening between the stomach and the duodenum), the balloon is inflated with air. The balloon is then moved along the intestinal tract by peristalsis (movement by alternate contraction and relaxation, in the case, of the intestinal walls. The rest of the tube is propelled along with the balloon.
The contents of the intestines are sucked back through the holes in the tube.
2separate openings outside the patient's body has a adapter with two openings.
1st opening is for suction and is marked "suction."
2nd opening is used by a doctor to inflate the balloon.

6. Gastric Lavage AKA: Stomach pumping 4/28/2017
Sequential administration & removal of small amounts of stomach contents.
Have suction on hand high risk for pulmonary aspiration
If pt is unconscious should be intubated to protect airway.
Block 3 & 4 just nice to know

7. Enteral Feeding Tube Duo Tube - smaller lumen weighted end
4/28/2017
Enteral Feeding Tube
Duo Tube - smaller lumen
weighted end
goes past stomach into duodenum
placement must be verified by x-ray before removing insertion wire.
Put nutrients into body
Made of polyurethane or silicone (radiopaque [position ID by xray]), long (to go past duodenum) small, soft and flexible.
Have to be inserted with guide wire
Placement past stomach should decrease regurgitation/aspiration
Disadvantages: more easily clogged & harder to check residual volumes.
prone to obstruction by in proper crushing of pills
failure to flush properly
can become dislodged by coughing, vomiting

8. Removal of Gastric Contents
4/28/2017
Removal of Gastric Contents
Order reads…
NGT to LIWS
(Low Intermittent Wall Suction)
NGT to LIS
(Low Intermittent Suction)
Policy/procedure example:
We will be using the Phoenix College Medical Center skill rubrics as our policy and procedure guide.

9. 1. Evaluate the nasogastric tube for patency.
4/28/2017
Question: What is the priority nursing action for the client who is complaining of nausea in the recovery room after gastric resection?
1. Evaluate the nasogastric tube for patency.
2. Call the physician for the antiemetic order.
3. Place client in semi-Fowler's position so that he will not aspirate.
4. Medicate the client with a narcotic analgesic.
Answer: 1
Rationale: Evaluate the nasogastric tube patency; it is important to prevent nausea and vomiting. The next action would be to put the client in semi-Fowler's position. It is very important to assess the client and take nursing measures to determine the source of the nausea and to decrease the nausea before calling the doctor.

10. Insertion of NG tube View the Video Skill at home
4/28/2017
Insertion of NG tube
View the Video Skill at home
Review the NGT practicum rubric
Practice in Lab
Insertion and maintenance of NG tube cannot be delegated.
Pull up and review our Review Rubric (policy).
Eguipment: 14 or 16 fr. NG tube (smaller tubes a not used for decompression
water soluble solution for lubrication
clean gloves
pH test strips
helpful: tongue blade, flashlight, emesis basin
catheter tipped syringe (60mL)

11. Insertion of NG tube X ray confirmation pH test 4/28/2017
X ray is the gold standard is x-ray confirmation.
A quick bedside pH test can be done with fluid obtained after the insertion.

12. Delegated Nursing Care
4/28/2017
Delegated Nursing Care
Measure output
Document amount of drainage & color & odor
Perform mouth care
Change nose dressing q day
Care of nares assess for irritation
Anchoring NG to gown with safety pin
Selected comfort measures

13. Contraindications Facial fractures
4/28/2017
Contraindications
Facial fractures
Obstruction in the nasopharyngeal or in the upper esophageal
Severe skull fractures or maxillofacial trauma
Severe case of uncontrolled coagulopathy
Nasal stenosis, astresia, mass
Comatose patients specifically those with unprotected airways
Patients known with tracheo- esophageal fistula and esophageal stricture
With severe facial trauma there is an increased risk for intracranial insertion of the NG tube which can worsen or cause neurological damage.

14. Complications Nasal trauma Gastric trauma Nasotracheal intubation
4/28/2017
Complications
Nasal trauma
Gastric trauma
Nasotracheal intubation
Mucosal damage
Entrapment
Tube into trachea : see tube misting
Also see: sinusitis, nose bleeds and sore throat

15. Irrigation of NG Tube Apply Gloves (bodily fluids)!
4/28/2017
Irrigation of NG Tube
Apply Gloves (bodily fluids)!
Check placement prior to irrigation!
Draw up sterile water or tap water with catheter tip syringe.
Clamp NG Tube & place towel under port.
Attach syringe.
Unclamp NG tube.
Flush slowly using a push pause method.
Clamp tube and remove syringe.

16. Medications Via NG Tube
4/28/2017
Medications Via NG Tube
Administer in meds in liquid form.
Crush pills, dissolve in warm water.
Give 1 at a time [best practice]
Always check placement prior to medication administration.
Check patency of tube by pre flushing.
Post flush after medication administration.
You must make sure only medications that can be crushed are placed down this tube.
It may be necessary to change the medication order to allow medications to be placed down a NGT

17. Removal of NG Tube Check provider order Gather supplies Dons gloves
4/28/2017
Removal of NG Tube
Check provider order
Gather supplies
Dons gloves
Instruct pt to sit up
Place towel on chest
Push a small amount of air to clear tube
Remove tape from nose & safety pin from gown!
Instruct pt to hold breath!
Prevents Aspiration!
Gently, smoothly & quickly pull tube out
Offer pt warm washcloth to cleanse face
Offer oral care
Supplies; towel & damp warm washcloth, blue pad, emesis basin
What else?: monitor po intake, for return of N/V

18. Abdominal Assessment 4/28/2017
The abdomen is divided into 4 quadrants typically. If you look at the internal organs and draw the transecting lines then you can easily see where organs can be found.

19. GI assessment Inspection Auscultation Percussion Palpation 4 quadrants
4/28/2017
GI assessment
Inspection
Auscultation
4 quadrants
LRQ, URQ, ULQ, LLQ
Percussion
Tympany
Palpation
Light only
Remember: We always look before we touch!
GI assessment varies from the typical format of IPPA to IAPP. The rationale for this is: touching the abdoent will alter the bowel sounds and not give accurate assessment data.
Percussion: Is tapping like we did for the lungs. It starts in the lower right quadrant continues to upper right to upper left to lower left. The same as auscultation!
21-20

20. Inspection Skin: Striae, scars, bruising Contour/Symetry
4/28/2017
Inspection
Skin: Striae, scars, bruising
Contour/Symetry
Pulsations or movements
Men breath abdominally women breath costally
Look across the abdomen for shadow and the shape; look for distention (shinny taught skin)
Abdominal masses can be seen on a thinner person
Movements: increased peristalsis
Pulsations: Abdominal aortic aneurysm (AAA) this is bad
Have pt void before this exam
HOB slightly elevated and knees flexed slightly: relaxes the abdominal muscles

21. 4/28/2017
Auscultation
Start where? LRQ, URQ, ULQ, LLQ chasing the bowel, listen in a few spots
Diaphragm to skin is best practice, warm the stethescope
Bowel Sounds
5-35 clicks or gurgles per min. so listen in each quad for at least 20 sec.
Absent bowel sounds are declared after 5 min. of continuous auscultating!
Best to listen between meals
Vascular Sounds
Bruits indicate turbulent or disruption of blood flow:
AAA or renal artery stenosis

22. Percussion clockwise 4/28/2017
Shifting Dullness. In a supine person, ascitic fluid (increased abdominal fluid) settles by gravity into the flanks, displacing the air-filled bowel upward. You will hear a tympanitic note as you percuss over the top of the abdomen because gas-filled intestines float over the fluid (Fig ). Then percuss down the side of the abdomen. If fluid is present, the note will change from tympany to dull as you reach its level. Mark this spot.
21-19
Now turn the person onto the right side (roll the person toward you) (Fig ). The fluid will gravitate to the dependent (in this case, right) side, displacing the lighter bowel upward. Begin percussing the upper side of the abdomen and move downward. The sound changes from tympany to a dull sound as you reach the fluid level, but this time the level of dullness is higher, upward toward the umbilicus. This shifting level of dullness indicates the presence of fluid.
Shifting dullness is positive with a large volume of ascitic fluid: it will not detect less than 500 mL of fluid.

23. Palpation Light palpation Bend knees Breathe slow
4/28/2017
Palpation
Light palpation
Bend knees
Breathe slow
Conversation to distract
Hand low not pointing down
1 cm depth (1/2 inch)
Save painful areas for last
Watch facial experession while performing
PALPATE SURFACE
Keep your own voice low and soothing. Conversation may relax the person.
With a very ticklish person, keep the person's hand under your own with your fingers curled over his or her fingers. Move both hands around as you palpate; people are not ticklish to themselves.
Alternatively, perform palpation just after auscultation. Keep the stethoscope in place and curl your fingers around it, palpating as you pretend to auscultate. People do not perceive a stethoscope as a ticklish object. You can slide the stethoscope out when the person is used to being touched.
Light and Deep Palpation
Begin with light palpation. depress the skin about 1 cm (1/2inch) with gently rotary motion. sliding the fingers and skin together. Then lift the fingers (do not drag them) and move clockwise to the next location around the abdomen.
The objective here is not to search for organs but to form an overall impression of the skin surface and superficial musculature. Save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination.
Watch for
Muscle guarding.
Rigidity.
Large masses.
Tenderness.

24. 4/28/2017
Any Questions?
The End.
I/O