Gastrointestinal Intubation

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Gastrointestinal Intubation
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Purposes of GI tubes

• To meet nutritional needs when oral intake not
  possible
• To decompress the stomach, remove gas and fluid
• To lavage the stomach, remove ingested toxins
• To diagnosis disorders of GI motility
• To treat an obstruction
• To compress a bleeding site
• To aspirate gastric contents for analysis

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Types of Tubes

• Short- Nasogastric tube
• Introduced from the nose to the stomach
• Levin and Gastric (Salem) Sump
• Used to remove gas and fluid from the upper GI
  tract or to obtain a specimen of gastric contents
• Sometimes used for meds or feedings

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Levin Tube

• Single Lumen (hollow part of tube)
• Size 14-18 French
• Made of plastic or rubber
• Circular markings on the tube serve as insertion
  guides
• Connected to low intermittent suction (20 to 80
  mm Hg)

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Gastric (Salem) Sump

• Double lumen catheter
• Plastic, 12-18 FR.
• Used to decompress the stomach, keeps it empty
• Smaller, inner tube (blue pigtail) vents the
  larger suction-drainage tube to the atmosphere by
  way of an opening at the distal end of the tube.

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Sump cont.

• Keeps the suction force at the drainage openings
  at less that 25 mm Hg to prevent capillary
  irritation.
• Connected to low continuous suction.
• Vent lumen kept above the clients waist.
• Anti-reflux valve- prevents the reflux of gastric
  contents out of the vent lumen.
• After suction lumen is irrigated, air is
  injected. Maintains a buffer of air between the
  gastric contents and valve.

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Types cont.

• Medium length- nasoenteric used for feeding.
  Example- Dobhoff
• Placed in the duodenum or jejunum by fluoroscopy
  (x-ray dept) or at clients bedside.
• Verified by x-ray before feedings begin.
• May take up to 24 hrs. to pass through the
  stomach into the intestines.
• Place client on right side to facilitate passage

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Types cont.

• Long- nasoenteric tubes introduced through the
  nose and passed through the esophagus and stomach
  into the intestinal tract.
• Used to aspirate intestinal contents-ie. gas and
  fluid (Decompression) to prevent intestinal
  obstruction.
• Due to ? peristalsis, prevents vomiting, reduces
  tension at the incision line and prevents
  obstruction.

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Types cont.

• Examples of long tubes
• Miller- Abbott- used for aspiration and
• weighted with mercury, water, or saline
• Harris- used for suction and irrigation
• mercury-weighted.
• Cantor- has a large balloon at distal end of
  tube. Filled with 4- 5 ml of mercury, water or
  saline to weight the tube.

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Inserting an NG Tube

• Provide privacy, wash hands, wear gloves
• Instruct and reassure client.
• Determine nares patency, length to insert.
• Measure from tip of nose to earlobe, earlobe to
  xiphoid process. Add 6 in. for NG, 8-10 in. for
  intestinal placement.
• Place client in Fowlers position,head tilted
  back slightly.
• Lubricate end of tube and insert until resistance
  is met at nasopharynx.

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Inserting cont.

• Have client tilt head forward until chin is near
  chest and ask client to sip water or ice chips
  and swallow. Aids in advancing the tube.
• Advance to measured circular mark.
• Have client open mouth and inspect orophayrnx to
  be sure tube is not coiled in back of throat.

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Confirming Placement

• Tube placement is confirmed prior to any use of
  the tube for suction, irrigation, medication
  admin. or feedings.
• Initially, an x-ray should be ordered to confirm
  placement of weighted feeding tubes (Dobhoff).
• Verify NG or Salem Sump tubes by auscultation of
  an injected air bolus over the epigastrium or
  aspirate stomach contents.
• Measurement of tube length, visual inspection and
  measuring of the aspirate pH is also
  recommended.

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Securing the GI tube

• Use a skin barrier to prep the skin
• Use NG strip or place a piece of tape under the
  tube at the nose and secure to the skin, place
  another piece of tape over the first piece.
• Secure tube to clients gown with a safety pin.
• Document Tube type and size
• Drainage or aspirate (residuals) amount, color
  and consistency
• Irrigation type and amount
• Suction- type and level (i.e. low intermittent)
• Feeding- type and amount
• Patient tolerance
• Patient/ Family education and response

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NG Suction

• Tube for decompression will be attached to
  Intermittent Suction- keep suction between
  20-80mm Hg.
• Continuous suction greater than 25mm Hg can cause
  damage to the gastric mucosa.
• Do not clamp or plug the vent lumen.
• A soft hissing sound will be heard from the vent
  lumen if its patent.
• Record amt. on IO
• Change cannister PRN, tubing q 48 hrs.

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NG Irrigation

• Obtain solution ordered by MD , water or saline.
• Wear gloves.
• Obtain irrigation set- 60cc syringe with tray and
  equipment to confirm placement of tube.
• Unclamp tube or disconnect from suction/ feeding.
• Check amount of residual if tube not connected to
  suction.

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Irrig. Cont.

• Draw up irrig. fluid in syringe (50-100ml).
• Connect to tube and gently instill irrigation
  fluid. DO NOT FORCE IRRIGANT.
• Instill air into vent lumen (15-20 cc for adult).
• Re-establish suction or feeding as indicated.
• Document irrigation type and amount suction
  type drainage amount and color and, how client
  tolerated the procedure.

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Tube Feedings

• Meet nutritional needs when oral intake not
  possible
• Advantageous over TPN
• GI integrity is preserved
• Normal insulin/glucagon ratios are maintained
• Admin. intermittent, bolus, continuous
• Accessed by nasogastric, nasoenteric,
• gastrostomy or jejunostomy tube

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Med. Admin. into an Enteral Tube

• Check MD order
• Check to be sure medications can be crushed or
  given through a tube (ie. enteric coated is never
  crushed).
• Follow 5 rights of Med. Admin.
• Disconnect tube from suction or feeding.
• Aspirate stomach contents- if less than 100cc of
  contents, reinstill back to client.
• If gt 100cc, return hold feeding x 1 hour, then
• aspirate again, may need to call MD

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Med. Admin. cont.

• Irrigate tube with 30-50 ml of irrigation fluid
  prior to med. administration.
• Mix with water or apple juice in med cup to
  dissolve.
• Use syringe to flow into tube by gravity or use
  bulb. Give each med separately.
• Irrigate tube with 30-50 ml of irrigation fluid
  after med. administration.
• Re-connect to suction or feeding.
• Document med. admin., tolerance

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Imbalanced nutrition/ fluids less than body
requirements R/T inadequate intake, diarrhea

• Weights, Intake and output
• Give supplemental water
• Monitor ability to tolerate feeding, labs
• Maintain tube function and decrease chance of
  bacterial growth
• Flush and change tubing and formula according to
  policy
• Observe for dehydration
• Decrease rate of feeding as ordered
• Administer feedings at room temperature

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Risk for infection R/T presence of wound and tube

• Monitor vital signs
• Monitor WBC
• Evaluate insertion site daily
• Wash with soap, water and pat dry daily unless
  otherwise ordered
• May apply dressing

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Nursing Mgmt. for clients with GI tubes

• Instruct client re purpose, procedure for
  inserting/advancing the tube.
• Confirm the NG placement.
• Advance the nasoenteric tube- Use CAUTION
• Gastric Surg. pts.- Do not reinsert!!! Call MD
• Monitor the client, keep HOB at 30 degrees,
  maintain tube function/patency.
• Provide oral and nasal hygiene and care.
• Monitor for complications- aspiration,
  constipation, diarrhea, N V, occlusion.
• Tube removal.