1. GASTROINTESTINAL SYSTEM PROCEDURES

2. 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

3. 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

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

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

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

7. 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)

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

9. 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

10. 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

11. 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

12. 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.

13. 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

14. 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

15. 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

16. 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)

17. GI TUBE FEEDINGS TUBES Nasogastric Nasoduodenal or nasojejunal
Gastrostomy
Jejunostomy

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

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

20. GI TUBE FEEDINGS
TYPES OF FEEDINGS
Bolus
Continuous
Cyclical

21. 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

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

23. 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

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

25. 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

26. 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

27. 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

28. 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

29. 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

30. COMPLICATIONS OF NG TUBE FEEDINGS
Aspiration
Vomiting
Diarrhea
Clogged tube

31. 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

32. 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

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

34. 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

35. 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

36. 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)

37. 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

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

39. 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

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

41. 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

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

43. 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

44. 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

45. 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

46. 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

47. ESOPHAGEAL AND GASTRIC TUBES
TYPES
Sengstaken-Blakemore tube
Minnesota tube

48. 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

49. 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

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

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

52. 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

53. 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

54. 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

55. LAVAGE TUBES DESCRIPTION
Used to remove toxic substances from the stomach

56. 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

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