NG tubes

What is the purpose of GI tubes?

It provides nutrition or gastric decompression

What is gastric decompression?

Removal of excess gas, fluid, or pressure, via a GI tube

Salem Sump

short double lumen tube for suctioning or feeding

Parts of the salem sump

1. Small lumen

2. Large lumen

3. Adapter

4. Anti Reflux valve

5. Graduation markings

6. Radiopaque marking line

What does irrigation mean?

The process of washing or flushing out the stomach. This may be used after swallowing poisonous material or drug overdose

Small lumen of the salem sump

Often blue and supports airflow. It is the air vent port. It allows the exchange of air into the stomach to stabilize the pressure. This is especially important during suctioning. DO NOT put anything down this port

Large lumen of the salem sump

It is usually the clear the lumen that we use. It may be connected to suction, or it is used to provide nutrition, medication, or irrigation

Adapter of the salem sump

Universal connector attached to the main suction lumen of a double-lumen NG tube to various sizes of clinical suction tubing and collection canisters

Anti Reflux valve of the salem sump

A one-way specialized valve attached to the blue vent lumen of the salem sump. This valve is designed to support airflow

Graduation markings of the salem sump

CM markings; printed directly along the length of the tubing to help clinicians measure insertion depth, verify accurate placement, and track any tube migration over time

Radiopaque marking line of the salem sump

X-ray strip embedded along the length of the clear plastic tubing. it allows healthcare workers to view position of NG tube inside the patient's body using x-ray, which is important for the confirmation of the placement

Dobhoff

single lumen with a smaller diameter and more flexible tube than the salem sump. Has a weighted tip. Cannot be used for suctioning, only used for feeding

Parts of Dobhoff

1. Guidewire

2. Valve

Guidewire of the dobhoff

Has a guidewire to help with placement and is also used to check for proper placement. Do NOT remove before x-ray. If you do, do NOT reinsert the guidewire. You will need to remove the whole device and start over

Valve of the dobhoff

Often connected to the dobhoff but not always. The Lopez Valve is the most common one used. It is a specialized three-way stopcock used with enteral feeding. It allows caregivers to administer medications, flush lines, or perform suctioning without opening or disconnecting the main feeding tube

Inserting NG tubes preprocedural highlights

-Always have an order

-DO NOT insert NG tube if septal defect or facial fractures. These patients are at risk of injury and tube may need to be inserted via endoscope or fluoroscope

-Check for gag reflex. Have them take a sip of water. If diminished or absent gag reflex, then the patient is at risk for aspiration

Inserting NG tubes before the procedure highlights

-Have them positioned in high fowlers

-Measure tube length from the tip of the nose to the earlobe and from the earlobe to the xiphoid process. Then mark the length to indicate the distance the tube must be inserted to reach the stomach

-Stand on the side of your dominate hand

-Prepare your fixation device before starting. Secure tubing tape to the nose

-Prepare a cup of water with a straw

-Lubricate the tip of the tube to prevent injury

Inserting NG tubes during the procedure highlights

-When inserting, you will feel slight resistance, but you should be able to gently advance forward - you should NOT use hard force

-Instruct the patient to flex their head forward towards their chest and take small sips of water. This helps close the trachea and open the esophagus, allowing easier advancement and decreasing risk of tubing entering the lungs. Advance the tube with each advance

-If the patient coughs during insertion - pull back and give them a moment before continuing. If they are fully distressed and you deem it dangerous to continue, then remove the tube and try again later

Inserting NG tubes after the procedure highlights

-Secure the tube placement then verify the placement

-Call for an x-ray. DO NOT USE THE TUBE UNTIL X-RAY CONFIRMATION

-Patients should have no trouble speaking once the tube is placed

-Pin the NG tube to the patient's gown/shirt

How often should x-ray location be assessed?

Every time the tube is used or once per shift (bare minimum)

Enteral nutrition

liquid nutrition provided via a tube into the GI tract. Indicates severe malnutrition or risk of malnutrition

Short term enteral feeding

Through the nose. No surgery needed and it is easy to remove. Nurses put in, in the room

Long term enteral feeding

Surgery through the abdomen.

Why are NGTs not used long term?

There is a risk of dislodgment (the tube coming out) and discomfort. People can get nose bleeds and nasal mucosal break down due to the tube

Types of short term tubes

NG tube: salem sump and dobhoff

NJ tube: nasojejunal tube

Types of long term tubes

G tube- directly into the stomach and common in PEG tubes

J tube- directly into the jejunum of the small intestine

G/T tube

these extend outward and require looping or taping

G/J button

sits flat against the body with a small cap and require an extension set only during feeding

Ways to confirm tube placement

-x-ray

-aspirate gastric pH

-auscultating air through the NG tube (NOT RECOMMENDED)

How do I know which formula to use for patients?

The type of formula selected is based on the patient's needs.

-High protein for wound healing or malnutrition.

-Diabetics need lower carb formula.

-Lower electrolytes for renal failure

-Higher fiber due to bowel dysfunction

Feeding schedules

-bolus

-intermittent

-cyclic

-continuous

-periodic

Continuous feeding

instillation of liquid nutrition without interruption. 24/7

Cyclic feeding

Feeding that cycles on and off

Intermittent feeding

involves delivering nutrition at scheduled intervals, either through medical tube feeding or dietary fasting, allowing periods of rest between feedings. Usually supportive nutrition, the patient can eat but needs additional nutrients

Periodic feeding

formula intake is based on their oral intake. If they ate enough maybe no feed or if they didn't maybe one feed or two. really depends on the patient's needs

Bolus feeding

Large single dose that resembles normal feeding patterns. Received maybe 300-400 mL of formula over 5-10 minutes (like a normal meal) then nothing

Open enteral system feeding

Requires formula to be prepared or transferred into a feeding bag, syringe, or other administration container before delivery. It requires more time to prepare and also increases the risk of contaminating the formula. Generally shorter allowable hang times than unopened hang systems because of increased contamination risk from bacteria.

Closed enteral system feeding

Also known as "ready-to-hang". This system uses pre-filled formula in sealed feeding containers. Decreased risk of contamination in comparison to open system

How to prevent contamination of enteral feedings

-Always check expiration dates and the appearance

-Do not clean and reuse tubes. Throw it away, it is meant to be used once

-Nonsterile gloves are used. This procedure is clean not sterile

What temperature should formula be before administering?

Room temperature, this decreases stomach discomfort and cramping

How long can closed system (sterile feedings) hang up for?

Less than 24 hours, but exact time depends on the policy

How long can open system (nonsterile feedings) hang up for?

Less than 4 hours, but exact time depends on the policy

How often should the feeding system, or tubing, be changed?

At least every 24 hours, but exact time depends on the policy

Sterile or nonsterile water for feeding flush

Usually, nonsterile water is used. Some patients may need sterile water. For example, immunocompromised or critically ill patients may need sterile water.

What is the name of the most common pump used to infuse feedings?

Kangaroo pump

Which type of feeding does not need a pump to be infused?

Bolus feedings

How do nurses decide which system to use for patient feedings?

It is greatly based on availability and feeding schedule. For example: some facilities may not have both closed and open systems.

-An open system would be better to use for bolus feedings

-While a closed system would be better to use for continuous feedings

VTBO

volume to be delivered

What position should the patient be in at all times during feeding?

Semi to High fowlers ALWAYS. Never lay the patient down

Oral care with an NGT

Provide oral care every 4 hours. Because the patient is NPO and the presence of an NGT, the mouth can become very dry. Provide mouth care and lip balm to prevent cracking.

Why is it important to weigh the patient during tube feeding?

To assess their nutritional status and determine if we are meeting their goals. Are we feeding them enough? Too much? It is also part of their continual assessment

Where should the feeding container be placed?

Always higher than where it enters the body. If not, it can cause back flow

Why is it especially important to assess bowel sounds during tube feedings?

Patients with absent or decreased bowel sounds may have decreased motility. The food is not moving through the GI tract; this can lead to feedings backing up and potential aspiration.

Indication of decreased motility or feeding intolerance

Vomiting, diarrhea, abdominal distention, abdominal discomfort, reduced passage of flatus or stool, backed up food imaging

Gastric residual volume

The amount of fluid aspirated from the stomach through a feeding tube; this is done to check how well a patient is digesting and emptying food from the stomach (a way of assessing gastric motility)

Residual

means left over or remaining after the main process is over. Essentially what is left over after digestion. Assessing residual prevents aspiration

Why is routine checking of GRV no longer recommended?

Because it can delay or interrupt feeding and therefore interfere with nutrition. It is also poor evidence for GRV correlating with aspiration- which is the main reason for it being done.

GRV signs of intolerance

250 mL. 500 mL or more requires holding the feed

When checking residuals, most locations require you to _____ what is aspirated

RETURN

What is irrigation used for?

Maintaining tube patency. Skipping this can lead to clogged tubes, blockages, and bacterial growth

What does the amount and frequency of irrigation depend on?

The physician's orders

When is irrigation done?

It is done before and after feeding, and before and after medication administration. Also often required every 4-8

How much fluid is typically irrigated?

30 to 50 mL.

PEG tube or percutaneous endoscopic gastrostomy tube

It is a flexible feeding tube placed through the abdominal wall directly into the stomach to deliver liquid nutrition, fluids, and medications. It is the most common tube used for long term feeding

G/J tube or button care

-Monitor skin. Perform a skin assessment. Check color, temp, moisture, skin integrity, discharge. Make sure gastric contents are not leaking because this can lead to skin breakdown. Make sure there is no discharge, especially yellow/tan/green or foul

-Monitor the bumper, it should not be tightly pressed against the skin

-Monitor dressing and remove, clean, and replace dirty gauze. If skin looks irritated and inflamed, change the dressing. SIDE NOTE: gauze can cause more skin irration

How do we clean G/J tubes or buttons?

Remove old dressing and clean with soap and water using a washcloth or cotton swabs. Pat dry and reapply gauze and tape. If the site is healed and it is at least 2 weeks old, the patient can shower without it covered

What do I do if the G/J tube or button falls out?

It must be replaced ASAP or else the opening will close. It can close within hours. If this happens, notify the health care provider immediately. Never try to reinsert on your own.

NGT skin and nare care

Monitor nasal mucosa and skin for breakdown, irritation, and redness. Prevent complications such as nasal mucosa erosion which is common and caused by the tube. Keep the tube stable and pinned to the gown/shirt. Monitor skin on the nose for breakdown caused by tape. Change tape anytime it loses adhesion or gets soiled. Be sure the area is clean and dry before applying new tape.

NG tube suction purpose

Gastric decompression. Used to remove excess air or fluid. Doing so prevents aspiration or that content from entering the lungs. It relieves pain, bloating, and nausea/vomiting.

Suctions can be orders as either...

Continuous or intermittent.

-Continuous is constant

-Intermittent will suction for a bit, then stop

Suction pressure range

High

Medium

Low

Low suction pressure range

Usually, this type is ordered. Ranged about 40-60 mm hg. Generally, not recommended to go above 80 because this can damage the gastric lining

Suction regulator: wall port

A medical device that converts high negative pressure from a hospital's central vacuum system into a safe, controlled level for patient care

Equipment needed for suction from an NGT

-Salem sump with an adapter to connect to suction tubing

-Suction regulator: wall port

-Suction tubing

-Suction cannister

Suction tubing

Comes with a long and short tube

Suction canister

The suction regulator and NGT are connected to the suction canister. Anything that is sucked up or removed from the stomach will enter the canister. You will monitor the outtake and assess the color/amount/consistency. This is considered output that will be tracked for I&O

3 ports on the suction canister

-Orthro port

-Vacuum port

-Patient port

Orthro port of the suction canister

An extra secondary opening on the lid designed for high-flow surgical tools or linking multiple canisters. Generally, not used on the floor.

Vacuum port of the suction canister

the port that you connect to the suction regulator

Patient port of the suction canister

The port that is connected to the patient via their NG tube

Nursing care during suctioning

-The patient is NPO during. May be allowed ice chips to relieve dryness

-Maintain HOB at least 30 degrees

-Irrigating the line is required every 4-8 hours. Even if the suction appears to be working, there is still a risk for the tube to clog or adhere to the gastric wall. During irrigation, stop suctioning, irrigate via gravity, then restart suction

-Assess drainage every shift, it is considered output that must be calculated for I&O

True Output

Output (what is in the suction cannister) minus what is irrigated (what is flushed in)

Which medications are NOT meant to be crushed and administered via a tube?

Enteric coated or time released medications. This can result in the medications being released and absorbed at a faster rate than they were designed to. Most often labeled: ER, XR, and enteric coated

Administering crushed medications

-Crush med to a fine powder and mix with 20-30mL of water

-Always flush BEFORE, BETWEEN, and AFTER meds

-Check tube placement before ever putting anything in the tube

-Patient should be in high fowlers

-Flush via gravity, NEVER using a plunger

-Use a 30 to 60 mL syringe

-One med per cup. DO NOT MIX MEDS

Nursing considerations for medication administration

-If a patient is on fluid restrictions, flush with the smallest amount possible (5-15 mL)

-If a patient is on feedings, hold the feeding, flush before and after administering meds, then restart feeding

-If a patient is on suction, stop suction before and keep it off 30-60 minutes after the med was given. This allows time for it to be absorbed

Removing an NG tube

-Make sure feeding has stopped for at least 30 minutes

-Stop suction first, not doing so can damage the patient

-Position in high fowlers

-Explain that it may be uncomfortable for their nose and they may gag

-Put a towel or chuck pad across the chest to prevent soiling their shirt or linens

-Flush tube with air to remove formula or secretions

-Unfasten the tube from the gown and nose then fold it in half in your hand

-Instruct the patient to take a deep breath and hold

-Quickly and steadily remove the tube without yanking it

-Throw the tube away

Troubleshooting enteral tubes

-Make sure it is connected to wall suction; tubes can come loose or perhaps the wall regulator was off

-Irrigate the Salem sump through the large lumen, this clears the tubing of content and releases from the stomach mucosa if it's caught by suction

-Review the air vent. It should be open to air. Fluid in the tube may block airflow. Therefore, flush the pigtail with air, but this should not be done routinely.

-If a Lopez valve is present, assess where the off suction is facing