1. Gastrointestinal Intubations
Module 5

2. Gastrostomy
Surgical creation of a gastric fistula through the abdominal wall, necessary in some cases of cicatricial stricture of the esophagus for the purpose of introducing food into the stomach.
Percutaneous endoscopic gastrostomy (PEG)
A feeding ostomy. PEG tubes are inserted through the esophagus into the stomach with the aid of an endoscope and then pulled through a stab wound made in the abdominal wall.
Nasogastric
the nostril to the nasopharynx and to the stomach

3. Ileus
failure of appropriate forward movement of bowel contents. It may be secondary to either mechanical obstruction of the bowel or a disturbance in neural stimulation (adynamic ileus).
Paralytic ileus
paralysis of the gut due to peritoneal contamination by pus (from a perforated appendix) or acid (from a perforated ulcer);
Underlying condition must be treated appropriately
Can also follow spinal cord injuries, pneumonia, and other general conditions. May occur after any abdominal surgery & can be a anticholinergic side effect of certain psychotropic drugs.
Usually temporary, with distention & symptoms of acute obstruction
The condition is managed by inserting a naso-gastric tube and aspirating the stomach contents.
The objective is to decompress and rest the intestine as this will relieve abdominal distention and vomiting.
Thereafter aspiration takes place at regular intervals (hourly) or the naso-gastric tube is placed on siphon drainage until the condition resolves.
Electrolyte and fluid balance are restored and maintained by giving crystalloid solutions intravenously with potassium being added as required.
If the patient does not improve rapidly with these conservative measures, an operation will be required to locate the obstruction and restore normal bowel continuity and function.

4. Gastrointestinal Tubes
Can be inserted via
Nose
Stomach
Many types can be inserted by nurses, but some of the larger, longer or multiple lumen tubes must be inserted by physicians or nurses with advanced training

5. Improper tube placement can lead to serious complications:
Esophagotracheal fistula
Gastric ulceration
Esophageal or gastric perforation
Aspiration pneumonia

6. GI tubes Instilling liquid foods or other substances
May be inserted for the purpose of
Instilling liquid foods or other substances
Establish a means for suctioning stomach contents to prevent gastric distention, nausea & vomiting
To obtain stomach contents for lab work
To lavage stomach in cases of poisoning or overdoses
Gastric decompression (to remove gas and or fluid)

7. Enteral Access devices
Access can be achieved via various routes
Nasogastric = inserted thru 1 of nostrils down nasopharnyx to alimentary tract (may also go mouth down but causes gagging++ and discomfort, more often in premies)
Nasoenteric inserted same as Nasogastric but extends down into upper small intestine (used with those with high risk of aspiration)
Gastrostomy, Jejunostomy = for longer term and placed via placement thru abd wall into stomach (gastrostomy) or into jujumen (Jejunostomy)

8. Nasoenteric tube (NET) is generally indicated for short-term therapy (< 6wks)
More permanent enterostomal devices for nutrition, such as a gastrostomy or jejunostomy tube, is appropriate for therapy expected to last a month to 6 weeks or more.

9. Types of GI tubes
Large Bore used for gastric decompression or analysis, or rarely for short-term feeding
Levin = single lumen tube Size 12 to 18F
Salem = double lumen, larger lumen for draining of gastric contents, smaller allow for inflow of air to prevent a vacuum if tube adheres to stomach wall
Small Bore
Nasogastric/feeding tubes – size 6 to 12F and inches long
Intestinal Tubes for decompression Hg-weighted balloon tips facilitate passing the tube beyond the stomach primarily for intestinal decompression (10 feet long)
Harris, Cantor or Miller Abbot
A Levin or Salem sump tube is used for gastric decompression or analysis, or rarely for short-term feeding.
Hg-weighted balloon tips facilitate passing the tube (eg, Miller-Abbott, Cantor) beyond the stomach for intestinal decompression or feeding. Very flexible, thin Hg- or tungsten-tipped tubes (eg, Corpak, Dobbhoff, Entriflex) are used mainly for prolonged enteral feeding.

10. Smaller diameter Smaller diameter tubes
Clog easier esp with thick feeds or when meds are tabs that have been crushed
Can also be dislodged by vomiting or coughing
Can become knotted or kinked in GI tract
If not flushed before and after, easily become clogged requiring a change of tube
More difficult to check residual volumes

11. Tubes for decompression

12. Tubes made of polyurethane or silicone
Radiopaque so position visible by x-ray
Tubes made of rubber or polyvinyl chloride stiffen with time

13. Procedures Inserting a NG tube – Kozier p. 1149
Removing NG tube – Kozier p. 1152
Managing GI suction – Kozier p. 872
Administering tube feed via NG tube – Kozier p. 1156
Administering feed via gastrostomy or jejunostomy feed – Kozier p. 1158

14. Purposes of NG tubes Decompression (remove fluids & gas from stomach)
Prevent or relieve N&V after surgery (by the decompression)
To determine amt of pressure & motor activity in GI tract
Irrigate stomach (lavage) after poisoning
Treat mechanical obstruction
Administer meds & nutrition
Obtain specimens (when pyloric or intestinal obstruction suspected)

15. Pts with intact gag & cough reflexes
NG tubes
Used with
Pts with intact gag & cough reflexes
Pts with adequate gastric emptying
Short term use

16. Inserting a NG tube
If rubber tube used, place on ice for 5-10 mins to stiffen tube
Make sure guide wire if present is secured in position
Measure distance (NEX)
Use only water soluble lubricant (muko) not Vaseline to lubricate tube
Have pt sit upright, head back
Once tube at throat (gag) have client tilt head forward and swallow
NEVER, NEVER, EVER FORCE A TUBE DOWN

17. Obtaining the NEX (nose, earlobe and xiphoid)
Some tubes may be pre-measured but this may not correlated exactly with the measurement obtained

18. TO CONFIRM PLACEMENT OF NG
Placement most reliably confirmed by x-ray
Can also aspirate for stomach contents or auscultate air insufflation
Aspirate for stomach contents = attach syringe to tube and apply gentle pressure. If contents return, tube is in place
Air insufflation = attach syringe, place stethoscope over pt’s epigastric region. Inject about 15-20ml of air and listen for “whoosh”
Ask pt to talk = if cannot talk, tube may be coiled in throat or passed through vocal cords

19. Methods to assess tube position
Test gastric aspirate for pH (1 – 4 – 6 {if pt on meds for gastric acid control})
Intestine aspirates at pH 6 & >
Resp aspirates at 7 & >
pH readings of 6+ indicate need for x-ray confirmation

20. Pt with NG tube Inspect nose for discharge and irritation
Will require
Inspect nose for discharge and irritation
Clean nostril and tube with moist q-tips
Apply water soluble lubricant to nostril if area dry, crusted
Frequent mouth care (q2h) as client will be NPO

21. NG problem solving
Pain or vomiting after insertion = indicates tube is obstructed or incorrectly placed
Not draining = may be obstructed or needs to repositioned then checked again for placement
If pt displaying signs of distress (gasping, coughing, cyanotic) remove tube immediately

22. Nurses responsibility
Assess gastric contents
Color
Consistency
Odor
Amount
Irrigate tube before and after meds/feeds
Check GI function by auscultation for bowel sounds

23. Key Elements in insertion of NG
Minimize discomfort by positioning pt appropriately, lubricating tip and informing pt what to expect
NEVER force the tube against resistance
Confirm placement of the tube
Secure the tube to the pt’s nose or nose and cheek

24. NG’s & suction, decompression
Kozier on p. 872
Suction can be ordered as
Continuous (can be set anywhere from mm Hg)
Intermittent (suction for secs then interval with no suction) usually at low setting
And
Low (pressure between mm Hg)
High (pressure between 100–120 mm Hg

25. Before initiating, 1st confirm tube in place
Can be connected to
Wall suction
Portable suction
By gravity
Before initiating, 1st confirm tube in place
Intermittent – usually with single lumen
Continuous – usually with double lumen (Salem)

26. NG’s & suction, decompression…
Low continuous suction or high intermittent pressure = Salem sump tube (ie has double lumen.
Larger lumen for draining of gastric contents, smaller allow for inflow of air to prevent a vacuum if tube adheres to stomach wall
If Levin tube used, low intermittent suction recommended

27. Key Elements to Remove NG
Turn off suction, disconnect tube from suction
Clamp tubing before removal
Wear gloves
Withdraw tube while pt holds his breath

28. Part B: Enteral Feeding & Meds
Oral feeding is preferred & most effective method but there are alternates for po nutrition including:
Enteral (thru GI system) and can be via
NG tubes
Gastrostomy or jejunostomy tubes
Parenteral (IV)
Alternates may deliver total or supplemental nutrition over short or long term

29. Common enteral feeding placement locations From Lewis on p. 1054

30. NG tubes for feeds
Until recently, large bore rubber or plastic feeding tubes were used for NG feeds. Problems with tubes (irritation, pharnygitis etc) led to development of more pliable, small bore feeding tubes
Now the are 8-12 Fr (36-43”long)
Have weights to assist introduction but also keep in place
Problem with smaller tubes is the difficulty to verify placement (difficult to aspirate & insufflating with air unreliable as get false positives – can sometimes hear the gurgle even if the tube is in the esophagus or lung)

31. Advantages of NG feeds:
Enteral Feeding & Meds
Short term – less than 6 wks
A NG or nasointestinal tube appropriate
Advantages of NG feeds:
Allows stomach to be used as natural reservoir (so regulates amt of food/liquid released into small intestine)
Presence of gastric juice may decrease risk of infection
Disadvantages of NG feeds
Potential aspiration into lungs
Uncomfortable
Pt’s with dysfunctional gag reflux or those unable to be in Fowler’s position not candidates

32. Enteral Feeding & Meds
Nasointestinal Tubes – inserted via nostril to upper portion of small intestine
Advantage: minimal risk for aspiration
Disadvantage: may develop dumping syndrome as food direct in ‘bolus’ into intestine (as pyloric valve in stomach cannot slow or regulate transit of food into intestine)
Volume of feed results in
Distention of intestine
Hypoglycemic reaction
Results in gas, bloating, crampy pain, weakness & dizziness
Bowel distention may be responsible for GI symptoms such as crampy abdominal pain, bloating, and diarrhea. Intravascular volume contraction due to osmotic fluid shifts is perhaps responsible for the vasomotor symptoms such as tachycardia and lightheadedness
Late dumping occurs 1-3 hours after a meal. Rapid delivery of a meal to the small intestine results in an initial high concentration of carbohydrates in the proximal small bowel and rapid absorption of glucose. This is countered by a hyperinsulinemic response. The high insulin levels are responsible for the subsequent hypoglycemia

33. Long Term Support accomplished by creating a an opening into:
Enteral Feeding & Meds
Long Term Support accomplished by creating a an opening into:
Gastrostomy (opening into stomach)
Jejunostomy (opening into jejunum)
Methods of feeding includes:
PEG (Percutaneous endoscopic gastrostomy)
Surgical or laproscopically placed gastrostomy tube

34. To insert requires (by a physician) local anesthesia,
More & more PEG’s are popular as can be safely inserted & removed at bedside or in OPD
To insert requires (by a physician)
local anesthesia,
passage of endoscope into stomach,
a small incision or stab wound thru the skin of the abdomen
pushing a cannula thru the incision
insertion of guide wire thru cannula
introduction & placement of PEG

35. Lewis, p. 1054

36. There are also low profile gastrostomy devices

37. Before feeds with PEG’s or NG
NG’s or NI’s placement should be confirmed:
After insertion
Before beginning meds or feeds
At regular interval during a continuous feed
Esp important with the smaller bore tubes (ie. 6-12FR)

38. For continuous feeds, check residual q4-6 hours
With NG’s and New PEG’s anticipate:
Measuring of residual before each feed
Measuring residual done to evaluate absorption of last feed (ie. Is there undigested formula from a previous feed)
If residual is more than last infusion or 150 ml, hold feeding for 1 hour and recheck.
For continuous feeds, check residual q4-6 hours

39. Assess bowel sounds prior to each feeding or for continuous feeds, q4-8h
Monitor for abdominal distention (would indicate intolerance to previous feed)
Monitor for diarrhea, constipation or flatulence (lack of bulk may cause constipation. Hypertonic or concentration of formula may cause diarrhea or flatulence)

40. Nursing care
Elevate head at least 30 degrees during feed and 1 hr following
Tube must be flushed before and after feeds, med admin or aspiration for patency
Delivery sets must be changed q 12-24hrs or according to policy

41. Opened cans must be stored according to manufacturer’s directions
Nursing care
Opened cans must be stored according to manufacturer’s directions
Clean skin and stoma area at least daily, should be qshift
Mouth care q2-4 hours

48. Lewis, p. 1054