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NSE211 > NG/PEG TUBES > Flashcards

NG/PEG TUBES Flashcards

1
Q

What are the signs and symptoms of dysphagia?

A
  • Coughing during eating
  • Change in voice tone or quality after swallowing.
    -Abnormal movements of mouth, tongue, or lips.
  • Incomplete oral clearance or pocketing of food or medications.
  • Pharyngeal pooling
  • Pts with difficulty in swallowing - increased risk for aspiration
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2
Q

What is silent aspiration

A
  • “Silent aspiration” occurs with neurological problems that lead to decreased sensation d/t no cough reflex, loss of gag reflex – Often do not show signs such as coughing when food enters the airway.
  • Silent aspiration accounts for most of the aspiration in clients with dysphagia following stroke
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3
Q

Who is involved with patients who have dysphagia from the collaborative team?

A

-Speech language pathologist (SLP) to test pt’s swallowing abilities at bedside.
-Physiotherapists to assists with positioning, strengthening exercises/ ambulation of pt o -Dietician involved with nutrient composition requirements.

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4
Q

What are some nursing interventions to minimize risk of aspiration?

A
  • Behavioral techniques - such as those involving postural changes or the swallowing maneuver.
  • Stimulation of the oral/pharyngeal structures. - Swallowing- chin tuck
  • Modifications of food consistency –Viscosity & texture of the food should be thickened; patients vary in their ability to swallow thin & thick liquids.
    -Thickening agents – many commercially available, starch-based food thickeners increase consistency of food & pre-thickened water, juice, coffee & other products are available.
  • Viscosity also influences the swallowing reflex & peristaltic activity.
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5
Q

In enteral feeding, how can a pt. experience diarrhea

A

when feed runs too quick, medications or an active infection

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6
Q

in an enteral feed, how can a pt. experience constipation

A

related to the type of formula used, and a change of high-fibre formula to resolve constipation

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7
Q

when is an enteral feed given to a client?

A
  • Pt cannot ingest food but is still able to digest food & absorb nutrients.
  • Pts with impaired level of consciousness, aspiration, esophageal obstruction.
  • Early feeding & adequate nutrition is important to patient recovery.
  • Pts who are ill have high nutritional requirements & can become malnourished very quickly.
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7
Q

what are some expamples of a short term and long terms enteral feeding

A

short term - NG/OG
Long term - PEG, Gtube, Jtube

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8
Q

How is a NG/OG tube inserted

A

A pliable tube is inserted through the nasopharynx into stomach and allows removal of gastric secretion and introduction of solutions into stomach

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9
Q

what is the use of an NG tube

A

reduces the risk of aspiration and promotes successful feeding

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10
Q

Purposes of nasogastic intubation

A
  1. Decompression
  2. Feeding
  3. Compression
  4. Lavage
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11
Q

what is decompression

A

Removal of secretions and gaseous substances from the gastrointestinal tract to prevent or relieve abdominal distension.

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12
Q

what are the type of tubes used in decompression

A

The levin (single-lumen tube with holes neat the tip. A sump may be connected to either a drainage bag or an intermittent suction device to drain stomach secretions) and Salem sump tubes (this tube has two lumina: one for removal of gastric contents and one to provide an air vent) are most common tubes used for stomach decompression.

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13
Q

what is feeding?

A

Instillation of liquid nutritional supplements or feedings into the stomach for patients unable to swallow fluid.

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14
Q

what is lavage?

A

Irrigation of the stomach in cases of active bleeding, poisoning, or gastric dilation.

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15
Q

what is compression ?

A

Internal application of pressure by means of an inflated balloon to prevent internal esophageal or gastrointestinal hemorrhage.

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16
Q

what kind of tubes are used in small bowel feeding tubes?

A

tungsten and KAO

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17
Q

Is a smaller diameter tube better than a larger diameter tube in enteral feeding?

A

small diameter tubes are more comfortable but can block more easily.

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18
Q

What is checked by the physician before starting small bowel feeding tubes?

A

placement of tube must be verified by X-ray

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18
Q

How is PEG inserted

A

Using endocopy, a gastrostomy tube is inserted through the esophagus into stomach and then pulled through a stab wound in the abdominal wall

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19
Q

types of PEG

A

if the tube ends in the stomach - it is called gastric tube or G tube
If the tube ends in the duodenum - duodenual tube
If the tube ends in the jejunum - J tube or jejunal tube
- inserted by physician

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20
Q

standard intact nutrients for enteral formula

A
  • Whole protein nitrogen source, used in pts with normal or near normal GI function, protein content varies
  • Most product contain - 1.0 kcal/ml
  • Most are lactose free
  • Products are fibre containing or fibre free
20
Q

Elemental formulas (1.0 to 3.0 kcal/mL)

A
  • Pre-digested nutrients that are easily absorbed for a partially dysfunctional gastrointesinal tract : most have low fat content or high % of medium chain tryglycerides, used in patients with severly impaired GI absorption
  • fluid restricted
  • Intact nutrients, calorically dense (2.0 kcal/mL)
  • renal - intact nutrients, low phosphorous and low K+
    Other type of disease specific - intact nutrients designed for feeding pts with diabetes, liver and renal failure
21
Q

enteral feeding methods

A

continuous and intermittent

22
Q

continuous

A
  • slower, consistent rate over 24 hrs
  • residual volumes are checked q4h and if volume is over 200ml, feed should be stopped
  • maintain elevation of head of bed for 30-60 mins after completion of feed
  • 4h of feed at a time is hung to prevent bacterial growth
  • flush with water if feed is stopped, as tube will block if feed is left sitting in tube
23
Q

intermittent

A

known as bolus feed, runs at a faster rate intermittently
- used when clients is being weaned off enteral and can slowly begin eating
- flush with 30ml of water after each feed to ensure tube is clear

24
Q

complications of enteral feeding

A
  • high gastric residual - due to poor absorption
  • fluid and electrolyte imbalance
  • aspiration
  • tube displcement and occlusion
  • altered absorption of medication
25
Q

interventions of enteral feeding

A

keep HOB - more than 30
assess, monitor, document and inform physician
may need prokinetic medication (manages consitpation)

26
Q

skin care for OG and NG tube insertion

A

prior to insertion, inspect nares, patency and skin breakdown
Skin breakdown can also occur from
- pressure from tube
- gastric secretion drainage
- infection
- use of proper hand hygiene when administering, changing tubes

27
Q

tube patency nursing management

A
  • irrigated with water before and after each feeding, drug administration, residual checks
  • tube not being used for continuous enteral feed should be flushed with 30-60cc in adults and 5-10cc in children with water every 4 hours to ensure patency
  • pt should be sitting/lying with the head of bed at 30 to 45 while on enteral feeds at all times
  • stop feed when HOB less that 30 to prevent aspiration
28
Q

how to ensure tube positioning

A

after insertion, tube length from insertion site to distal must be measured and recorded
- initial placement is confirmed through x ray
- placement is checked before and after each feeding or every 8h with continuous feed or if there is any indication that tube has shifted position

29
Q

problems with enteral feeding

A

causes of clogged tube:
- improper flushing of tubes
- rate of flow could allow enteral formula to clump and cause buildup on sides of feeding tube
- medications that are not properly crushed can cause a blockage

29
Q

how to prevent a clogged tube

A

flush with water and flushing pre and post medications

30
Q

how to flush a tube?

A

-use 60cc syringe, draw up warm water and insert with gentle pressure into feeding tube
- avoid small syringes as they can cause high pressure and damage the tube

31
Q

medical management of blocked feeding tubes

A

sodium bicarbonate with 10ml water to tube, clamp x5 min and then flush
- proteolypase caps
- goal is to dissolve blockage and reestablish patency of the tube

32
Q

Assessment for enteral feeding

A
  • check tube placement
  • assess bowel sounds
  • daily weights
  • Accurate intake and output
  • blood glucose levels
33
Q

feeding protocol: enteral feeding

A
  • rate of administration
  • goal rate is calculated based on pt size, age, health status and nutritional feeds, may start slow and increased incrementally until target rate is achieved
  • feeding pump is often used to deliver the feeding and it can be programmed to deliver hourly rates of feeding
34
Q

complications of enteral feeding: Vomiting

A
  • Assess, position pt to minimize aspiration risk, Patient should always be sitting or have the HOB at 30-45 degrees while on enteral feeds
  • If nauseated consider antiemetics, inform physician & document.
  • Hold feeds or place NG to suction if ordered.
35
Q

complications of enteral feeding: Abdominal distention or cramping

A
  • Mild – check for constipation, inform physician if moderate or severe & document.
    -Moderate – check for bowel obstruction.
  • Severe – place NG to suction if ordered.
36
Q

diarrhea - complication of enteral

A
  • Mild – 1-2 x/shift - maintain & determine if any other causes.
  • Moderate – 3-4 x/shift - maintain – re-evaluate in 6 hr.
  • Severe - >4 x/shift - inform & document physician. o May need to decrease rate by 50% & monitor* check agency policy.
37
Q

constipation - complication of enteral

A

-consider stool softeners and water boluses
- inform physician and document

38
Q

medication administration via gastric tubes

A

If a client has a gastric tube, generally all of the PO medications are administered using the gastric tube

39
Q

What is the process of administering medication via gastric tube?

A

Verify tube placement usually by aspiration (follow agency policy).
- Prepare medication by crushing and dissolving in warm tap water.
-Do not crush medications that have a long acting or extended-release formulation, or enteric coating.
-Administer one medication at a time. Ensure compatibility with feeding. May require holding feeding prior to and after administration mediation should not be taken with food.
-Never add medication directly to the feeding container.
-Stop feed, flush with 15-30ml water before and between meds and flush again with 30-60 ml at end and before restarting feeding (depending on hospital policy) unless contraindicated by patient condition (e.g., fluid restriction, inability to tolerate excess volume with large number of meds)

40
Q

gastric decompression

A

Gastric decompression is the use of suction to drain the stomach to relieve blockage of the intestinal tract, to wash out stomach contents when a person has taken poisonous material or after surgery
- After surgery, the objectives for drainage are as follows:
- Reduce abdominal distension.
- Speed the return of bowel function.
- Reduce the chance of wound dehiscence and hernia.

41
Q

gastric ph range

A

1.5-3.5

42
Q

inserting a large bore nasoenteric or orogastric tube for gastric suctioning

A
  1. Assess the need for large bore tube (gastric suctioning/lavage)
  2. Perform HH and assess patency of nares and skin breakdown. Have pt. close each nostril and breathe
  3. assess gag reflex. Place tongue blade in pt. mouth, touching uvula to induce a gag response
  4. review pt medical history for nasal problems - nasoenteral tubes are contraindicated
  5. auscultate pt. abdomen for bowel sounds, may indicate decrease in or absence of peristalsis and increased risk of aspiration or distention
  6. explain procedure and how to communicate during intubation
  7. Stand on same side of bed as naris for insertion and assist pt. in high fowlers. Place pillow behind head and shoulders (easy manipulation of tube, reduces risk of aspiration and promotes effective swallowing)
    8.place absorbent pad over pt. chest and keep facial tissues within reach (may cause them to tear up)
  8. determine length of tube to be inserted and mark w tape
  9. Place NG/OG tube for intubation, Cut tape 10cm long or prepare tube fixation device. Split one end of tape lengthwise 5cmm, used to anchor tubing after insertion
  10. dip tube with lubricat into glass of water. If tube is not self lubricating - add water soluble lube
    12.insert tube through nostril to back of throat and aim back and down toward ear. Natural contour facilitates passage of tube into GI tract and reduces gagging by pt
  11. have pt tilt head toward chest after tube has passed through nasopharynx
  12. emphasize the need to mouth breathe and swallow during procedure - facilitates passage of tube and alleviate fears about procedure
  13. when tip of tube reaches the carina, stop insertion, hold end of tube near your ear and listen for air exchange
  14. check for position of tube behind throat with penlight and tongue blade
  15. to verify placement of tube - x-ray (prior to insertion) and ph measurement
  16. examine gastric content and yield - Aspirating gastric contents yields a greater amount, whereas aspirating respiratory contents may yield only a few millilitres.
  17. after gastric aspirated are obtained, anchor tube to pt. nose and avoid pressure on nares. Mark exit site on tube and select type of securing:A. apply tape:
    - Apply tincture of benzoin or other skin adhesive on tip of patient’s nose and tube and allow it to become “tacky”. Skin adhesive helps tape adhere better and protects skin.
    - Place intact end of tape over bridge of patient’s nose. Wrap each of the 5-cm strips around tube as it exists nose. Securing tape to nares prevents tissue necrosis.
    B. Apply tube fixation device, using shaped adhesive patch
    - apply wide end of patch to bridge pt. nose
  18. Fasten end of NG tube to pt. gown with tape as this reduces traction on naris if tube moves
  19. insepct naris for irritation and observe any difficulty breathing, coughing, gagging. Auscultate lung sounds
43
Q

A nurse had decided to plan the enteral feeding schedule and the type of tube to be used for a pt, with gastric suctioining. 2 weeks later she gets deported. why was what she did wrong?

A

procedure and tube feeding along with enteral feeding schedules require a physician order

44
Q

why is gag response important to assess when inserting a NG/OG tube?

A

Assessing gag reflex identifies patient’s ability to swallow and determines risk for aspiration.

** Patients with impaired level of consciousness or who are intubated and sedated may also have impaired gag reflex, and their risk of aspiration is increased during this type of procedure and subsequent tube feedings. If pt is Intubated, sedated, or too ill: ensure that the patient’s head is titled toward the chest for enteral feeding tube insertion.

45
Q

how to determine length of tube to be insertd for NG/OG tube

A
  1. traditional method - measure distancefrop tip of nose to earlop to xiphoid process of sternum
  2. for duodenal or jejunal placement - additional 20-30cm is required
46
Q

why is lube added before insertion

A

Activates lubricant to facilitate passage of tube into naris to gastrointestinal tract.

47
Q

why should the pt. tilt head forward after insertion

A

Titling head forward closes off glottis and reduces risk of tube’s entering trachea. This technique is also used in patients who are in intubated and sedated.
**Encourage pts. who are alert and able to swallow by giving small sips of water or ice chips. If pts. who are intubated and sedated or not able to participate, tilt head toward chest. Advance the tube as patient swallows or as head is tilted toward chest. Rotate tube 180 degrees while inserting.

48
Q

why should we listen for air exchange when tube reaches the ear in NG/OG tube insertion

A

If air is heard, the tube could be in the respiratory tract; remove tube and start over. This listening step should never be used to verify tube placement. If patient starts to cough, choke, or become cyanotic do not force tube insertion, and stop advancing the tube and pull tube back.

49
Q

after insertion of tube is done, why do we check the postioning of the tube behind the throat

A

Tube may be coiled, kinked, or entering trachea withdraw immediately it tube is coiled, if respiratory status of patient changes, or if patient beings to cough and skin colour changes; if distress is not present, withdraw tube fully and retry.

NSE211 (6 decks)

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