1. Gastrointestinal Intubation
Karen Malt, MSN, RN

2. Gastrointestinal Intubation
Often used for clients undergoing gastric or intestinal surgery.
Reduces the or eliminates problems associated with surgery or conditions affecting the GI tract, such as peristalsis, vomiting, or gas accumulation.
Tubes can also be used to nourish clients who cannot tolerate food orally.

3. Intubation
Placement of a tube into a body structure, in this section, it refers specifically to a tube in the stomach or the intestine by way of the mouth or the nose.
Orogastric Intubation- insertion of a tube through the mouth into the stomach.
Nasogastric- insertion of a tube through the nose into the stomach.
Nasointestinal intubation- insertion of a tube through the nose to the intestine
Performed to remove gas or fluids or to administer liquid nourishment.
A tube may also be inserted within an ostomy (Surgically created opening). A prefix identifies the anatomical site of the ostomy.
Example: Gastrostomy

4. Gastric or Intestinal Tubes Uses:
Performing a Gavage – Providing Nourishment
Administering oral medications that the client cannot swallow.
Obtaining a sample of secretions for diagnostic testing.
Performing a Lavage (removing substances from the stomach, typically poisons)
Promoting decompression (removing gas and liquid contents from the stomach or bowel.
Controlling gastric bleeding, a process called compression or tamponade (pressure).

5. Nasointestinal Tubes (longer than nasogastric)
Tubes inserted through the nose for distal placement below the stomach.
Added length allows for placement in the small bowel.
Used to provide nourishment.
Used to remove gas and liquid contents from the small intestine (decompression).

6. Feeding Tubes (Nasointestinal tubes used for nutrition).
Dobhoff – small in diameter and made of a flexible substance such as polyurethane or silicone. Narrow width and soft composition allow them to remain in the same nostril for 4 weeks or longer. They also reduce gastric reflux because they deliver liquid nutrition beyond the stomach.
Narrow tubes tend to curl during placement because they are so flexible. Therefore, some are supplied with a stylet (metal guidewire) that helps support the during insertion.
These tubes become obstructed more easily. Checking placement of the distal end of these tubes is more difficult also.
These tubes are preferred for their comfort, and are ideal for a continuous flow of nourishment.

7. Intestinal Decompression Tubes
Surgery is often the most common intervention when a client has a partial or complete bowel obstruction, intestinal decompression (removal of gas and intestinal contents) may be used.
A tube used for intestinal decompression has a double lumen and a weighted tip.
One lumen used to suction the intestinal contents
The other lumen is a vent to prevent trauma to the intestine from the suction.
At one time, mercury weighted tubes were used, but due to environmental and client risk, mercury tipped tubes are no longer used.
Today, mercury weighted tipped tubes are made with tungsten.

8. Transabdominal Tubes Tubes placed through the abdominal wall.
Gastrostomy Tube or G-Tube- (A transabdominal tube located within the stomach) placed surgically or by using an endoscope.
PEG Tube- Percutaneous endoscopic gastrostomy anchored in place with internal and external crossbars called bumpers.
PEJ Tube- Percutaneous Endoscopic Jejunostomy Tube; A tube passed through a PEG tube into the jejunum.
Jejunostomy Tube or a J-Tube- (A transabdominal tube that leads to the jejunum of the small intestine).
Transabdominal Tubes are used instead of nasogastric or nasointestinal tubes when clients require an alternative to oral feeding for more than one month.

9. Nasogastric Tube Management
Nurses usually insert nasogastric tubes.
Additional nursing responsibilities includes:
Keeping the tube patent
Implementing the prescribed use
Removing the tube as ordered.

10. Nasogastric Tube Insertion
Client Preparation:
Explain the procedure to the client.
Reducing anxiety by explaining that the tube is smaller in diameter than most pieces of food. Also, explain that the client can be of help while passing the tube. Make sure the client has some measure of control during the procedure. Allow the client to determine when a pause is necessary during the passing of the tube.

11. Nasogastric Tube Insertion (cont.)
Pre-Intubation Assessment- Prior to inserting an NG Tube the nurse should conduct a focused assessment that includes the client’s:
Level of Consciousness
Weight
Bowel Sounds
Abdominal Distention
Integrity of Nasal and Oral Mucosa
Ability to swallow, cough, and gag
Any Nausea and Vomiting
NOTE: Assessment findings serve as a baseline for future comparisons and may suggest a need to modify the procedure or the equipment used. One MAIN GOAL is to determine which nostril is best, and the length to which the tube will be inserted.

12. Nasogastric Tube Insertion (cont.)
Nasal Inspection-
After the client clears debris by blowing into a tissue, the nurse will inspect nostril size, shape and patency. The client should exhale while each nostril I turn is occluded.
The following excludes a nostril from being used;
Presence of nasal polyps (small benign growths)
A deviated septum ( nasal cartilage deflected from the mid-line of the nose)
Narrow nasal passage

13. Nasogastric Tube Insertion (cont.)
Nasogastric Tube Measurement;
Obtain the Client’s NEX Measurement;
Length From NOSE to EARLOBE to the XIPHOID Process (tip of the sternum). See Figure 29-5
The first mark is made from the measured distance from the nose to the earlobe. It indicates the distance to the nasal pharynx. A second mark is made at the point where the tube reaches the xiphoid process, indicating the depth required to reach the stomach.

14. Nasogastric Tube Placement
When inserting an NG Tube it is a Primary concern of the nurse to:
Cause as little discomfort as necessary.
To preserve the integrity of the nasal tissue.
Locate the tube within the stomach, NOT THE RESPIRATORY PASSAGES!

15. Nasogastric Tube Placement
Confirming Placement of the distal end of an NG Tube
Auscultation of the abdomen while instilling air.
Testing the pH of aspirated fluid
NOTE: Both of these methods lack 100% reliability. See page 665 Timby for complete details.
The only evidenced based methods for determining the distal location of an NG tube include obtaining an abdominal x-ray after its initial insertion and monitoring its external length (the “X” marked component of the NEX measurement to the proximal end of the tube) after radiographic confirmation.
Once the nurse has confirmed placement, he or she secures the tube to avoid upward or downward migration. The tube is then ready to use. View the video below on Inserting an NG Tube.
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16. Checking Placement of Intestinal Feeding Tubes
Initial tube placement is verified by X-Ray. Other techniques for confirming placement of small-diameter nasogastric feeding tubes are less reliable, but may be used by some. Nevertheless, repeated X-rays to confirm placement are expensive and impractical, and potentially harmful.
Nurses may verify distal tube placement throughout its use by:
Aspirating fluid from the tube after the initial X-Ray using a large volume syringe (30-50 ml). The large volume syringe creates less negative pressure during aspiration and therefore provides enough fluid to test the pH.

17. Use/Maintenance of Nasogastric Tubes
Nasogastric tubes are connected to suction for gastric decompression or are used for tube feeding.
Gastric Decompression- Suction is either continuous or intermittent. Continuous with an unvented tube can cause the tube to adhere to the stomach mucosa causing irritation and interfere with drainage. Using a vented tube or intermittent suction prevents this from occurring.
The tube is connected to a wall outlet or a portable suction machine.
The suction setting or amount is prescribed by the physician. Usually low pressure (40-60 mmHg) is used. The tube is clamped or plugged during ambulation or after instilling medications (See Chapter 32).

18. Use/Maintenance of Nasogastric Tube (cont.)
Restoring Patency- The nurse will assess tube patency frequently by monitoring the volume and characteristics of the drainage and observing for signs and symptoms of obstruction (Nausea/vomiting, abdominal distention.) Depending on the cause of the obstruction the nurse may need to irrigate the tube, and an order must be obtained prior to irrigation of the tube.
Promoting Patency-
Giving intermittent ice chips sparingly
Giving small sips of water sparingly
Giving too much water may deplete serum electrolytes. (See page 668 Timby.)

19. Enteral Nutrition
Nourishment provided through the stomach or small intestine rather than the oral route. Although a NG tube can be used, it is more likely that liquid formula will be administered through a nasointestinal or transabdominal tube.

20. Removal of a Nasogastric Tube
Nasogastric tubes are removed;
When the client’s condition improves
When the tube is hopelessly obstructed
When the time has lapsed (by the agency policy) to allow the NG to stay in place in order to maintain nasal mucosa.
Unobstructed Larger diameter tubes are usually removed and changed every 2 – 4 weeks for adults.
Small diameter flexible tubes are removed and changed every 4 weeks to 3 months (depending on the agency policy).
Tubes used for pediatric clients are changed more frequently due to the fragility of the tissue of a pediatric client and greater potential for infection.
Note: Before removal of a tube; the physician usually prescribes a “trial period” during which the tube is clamped and the client is allowed to consume oral fluids. If the client remains asymptomatic, that is a very good indication the tube is no longer necessary. If the client becomes symptomatic, the tube is still in place and can be easily reconnected to suction. View the following video below on NG Tube Removal.
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21. Insertion of a Nasointestinal Tube
The techniques for client preparation, positioning, and advancement of nasointestinal tubes are similar to those for NG tubes. Some modifications are necessary.
To estimate the length, the nurse determines the NEX measurement and adds 9 inches. Mark the additional measurement on the tubing.

22. Transabdominal Tube Management
The physician inserts transabdominal tubes such as:
G-tubes
J-Tubes
Note: the nurse is responsible for assessing for and caring for them and their insertion sites. Conscientious care is necessary as G-Tubes may leak and cause skin breakdown.
See Causes of Gastrostomy Leaks; Page 670 Timby

23. Tube Feedings
If oral feedings are impossible, or jeopardize client safety, nourishment is provided enterally or parenterally. Tube feedings are used when:
clients have an intact stomach or intestinal function but are unconscious,
have undergone extensive mouth surgery
have difficulty swallowing
have esophageal or gastric disorders.

24. Benefits and Risks of Tube Feedings
Gastric feedings increase the potential for gastric reflux , although the placement of tubes within the intestine reduces the risk for gastric reflux.
Intestinally placed tubes may lead to “dumping syndrome.” A cluster of symptoms from the rapid dumping of calorie dense nourishment into the small intestine. Symptoms include; weakness, dizziness, sweating, nausea, and are caused by fluid shifts from the circulating blood to the intestine and a low blood glucose level related to a surge of insulin. Diarrhea may also occur when administering hypertonic solutions.
Benefits;
Instilling nutritional formulas into the stomach uses the body’s natural reservoir for food.
Reduces the potential for enteritis (inflammation of the intestine) because the chemicals in the stomach destroy microorganisms.

25. Formula Considerations
Type of tube
Access Site
Client Nutritional Needs
Client weight
Nutritional status
Concurrent medical conditions
Projected length of therapy
The Feeding Schedule Affects the Choice of Formula- Calories may need to be concentrated if the client is being fed several times a day rather than continuously.

26. Tube-Feeding Schedules
Bolus Feedings- the instillation of liquid nourishment in less than 30 minutes four to six times a day usually involves 250 mL – 400 mL of formula per administration.
This schedule is the least desirable because it distends the stomach rapidly, gastric reflux, and discomfort. Clients who are unconscious or who have delayed gastric emptying are at greater risk for regurgitation, vomiting, and aspiration with this method.

27. Tube Feeding Schedules
Intermittent Feedings- The gradual instillation of liquid nourishment four to six times a day over 30 – 60 minutes. The usual volume is 250 – 400 mL.
Generally given by gravity drip by a suspended container or via a pump.
Gradual filling of the stomach creates less discomfort, less bloating.
The container and feeding tube that holds the formula requires thorough flushing after each feeding to reduce the growth of microorganisms.
Tube feeding administration sets are replaced every 24 hours regardless of the schedule.

28. Tube Feeding Schedules
Cyclic Feedings- the continuous instillation of liquid nourishment for 8 – 12 hours is followed by a 16 – 12 hour pause.
This routine is often used to wean clients from the feedings, while continuing to maintain adequate nutrition.
The tube feeding is given during the late evening and hours of sleep.
During the day, clients may eat some food orally.
As oral intake increases, the volume and duration of the tube feeding gradually decreases.

29. Tube Feeding Schedules
Continuous Feedings – The instillation of liquid nourishment without interruption at a rate of approximately 1.5 mL/minute.
Feeding pump is used to regulate the instillation.
Only a small amount of feeding is instilled at an interval.
This formula can be delivered right into the intestine.
Instilling directly into the intestine reduces the risk of vomiting/aspiration.
Inconvenience due to the pump having to be transported wherever the client goes.

30. Tube Feeding/Client Assessment
Standard Daily Assessments
Weight
Fluid Intake and Output
Bowel Sounds
Lung Sounds
Temperature
Condition of the nasal and oral mucous membranes
Breathing Pattern
Gastric Complaints
Status of Abdominal Distention/Vomiting
Bowel Elimination Patterns
Skin condition at the site of transabdominal tube

31. Tube Feeding/Client Assessment
Gastric Residual-
The volume of liquid inside the stomach.
The nurse measures the residual to determine whether the amount exceeds the client’s physiological capacity.
Overfilling the stomach can cause reflux, regurgitation, vomiting, aspiration, and pneumonia.
As a general rule, the gastric residual should be no greater than 100mL, or no more than 20% of the previous feedings total volume.
If the gastric residual is high, the feeding is stopped, and the residual is rechecked every 30 minutes until it is within a safe volume for resuming the feeding.

32. Nursing Management/Feeding Tube
Maintaining Patency-
Tubes smaller than 12 Fr are prone to obstruction.
Flush feeding tubes with 30 – 60 mL of water immediately before and after administering feeding or medications, after any interruption in feeding, every 4 hours if the client is being continuously fed, and after refeeding the gastric residual.
Contraindications for flushing would involve those clients on fluid restrictions.

33. Nursing Management/Feeding Tubes
Clearing an Obstruction –
Notify the physician
Warm water with back and forth motion
Instilling fluid activated pancreatic enzyme mixed with 1/8 teaspoon of sodium bicarbonate followed by allowing it to sit for 30 minutes before attempting to flush again.
Bionix Feeding Tube Declogger
Tube Clear System (a stem with a wire encased within a sheath).
When an obstruction cannot be cleared, the tube is removed and another inserted.

34. Nursing Management/Feeding Tubes
Providing Adequate Hydration
Clients will usually require additional hydration.
The nurse must identify the amount of water on the label of the commercial formula. Add this amount to the total volume of flush and compare it to the recommended amount. If there is a deficit, increase the volume or flushing of tube. If the fluid volume is excessive, the nurse monitors the clients urine output, and lung sounds to determine whether or not the client can excrete comparable amounts.

35. Preparing for Home
Clients can be sent home from hospitals and other types of facilities with tube feedings in place.
Before demonstrating the procedure to those who will administer tube feedings, the nurse will provide a written instruction sheet that includes;
Places to obtain equipment/formula
Guidelines for delaying a feeding
Special instructions for skin, nose, stomal care.
Problems to report such as weight loss, reduced urination, diarrhea, N/V, breathing difficulties.
Names/phone numbers of people to call for assistance.
Date, time, place for follow up appointments.
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36. Intestinal Decompression
Most NG, nasointestinal, and transabdominal tubes are used for enteral feeding and gastric decompression. Sometimes clients require intestinal decompression which is performed with a tungsten weighted tube.
Intestinal decompression sometimes makes it possible to avoid surgery.
See page 675 Timby for complete details.