Flashcards in Week 13 Part 2: Tube Feeds Deck (55):
Candidates for tube feeding?
Those who have adequate digestion + absorption but cannot ingest, chew, or swallow food safely or in adequate amounts.
Most serious complication of tube feeding?
What kind of tubes are usually used in short term tube feeds?
nasogastric (NG) and orogastric (oR) and nasoenteric.
When is gastrostomy or jejunostomy tube indicated?
When feeding is going to be more than 4 weeks long
Or nose + mouth contraindicated
Who determines what kind of feeding a pt will get?
Dietician + nurse + physician collaborate to determine this
Most serious complication of NG tube insertion?
Inadvertent pulmonary intubation
Is small intestine feeding reliable preventative of pulm respiration?
Evidence is mixed...most recent doesn't seem to indicate this
What techniques can be used during insertion to inc chances of putting tube in right place?
Capnogaphy (CO2 sensor on end of tube)
What height of bed should be maintained during feeding?
At least 30 degrees, preferably 45
Why is measurement of gastric residual volumes done?
To ID risk of regurgication + pulm aspiration of gastric contents
*Done at regular intervals during tube feeding
Can a decision to stop tube feeding be made solely based on GRV amounts?
What is the upper limit of GRV before indicates need to stop feeding?
No, this also has very mixed evidence...researchers agree must assess whole clinical condition in addition.
Is a range...some say 250-500mL.
If oral intake is not contraindicated for TF patient, what can be done around meal times to help psychological wellbeing?
Can still be encouraged to have oral intake
This can help to to sustain the social and psycological significance of meal time.
Factors that increase risk for complications r/t feeding tube insertion?
Impaired gag or cough reflex
Downside of wires put into NG tube during insertion?
Higher risk of pulm or esophageal injury
Nasal tube feeds contraindicated when?
Other things to look for in pt hx that may require alternate procedure?
basiliar skull # or facial trauma (may go through mouth in this case)
- hx of nasal problems, nosebleeds, facial trauma, nasal-facial sx, deviated septum, anticoagulant therapy, coagulopathy
Why is it important to look at a pt's coagulation status before tf insertion?
Because anticoag + bleeding disorders for epistaxis (nose bleed) during nasal tube placement
What should you get pt to do to indicate gagging or dicomofrt during tf insertion?
Can have raise index finger
If pt needs to be supine, what position for tf insertion?
What might you want to attach to pt to monitor during insertion procedure?
How do you prepare a NG or nasoenteric tube for intubation?
Inject 10mL H2) using 30-60mL luer-lok or catheter tip syringe (to ensure patency)
If using stylet, make certain that is it positioned securely within tube
How should patient be instructed to breath during insertion procedure?
What to do when tip reaches level of carina (bifurcation of trachea into two bronchi)
Where is this?
Stop and listen for air exchange from distal portion of tube (if can head breath sounds, may indicate is in resp tract. Must remove)
What might indicate intubation into resp system? What to do?
Pt coughing, drop in O2 saturation, other signs of resp distress
WIthdraw tube into posterior nasopharynx until normal breathing resumes
What to do immediately after tube insertion to check placement?
Aspirate contents + check pH
What must be done prior to removing stylet from the ng tube after insertion?
Is it ok to reinsert style when tube is in place
xray ensures correct placement
- Never try to reinsert a partially or fully removed stylet while tube feed is in place (may perforate wall of tube + cause injury)
What to instruct pt to do while you remove tube feed?
What to do with tube prior to removal?
Take deep breath + hold it
Kink tube by folding it over on itself to prevent residual fluid in tube from flowing out.
What do if aspiration of stomach contents into resp tract, evidence by ausculatation of crkcles, wheezes, dysnea or fever?
- report changes to hc provider (suggest xray if not one recently done)
- Position pt on side
- Suction nasotracheally or orotracheally
- Prepare for possible initiation of abx
Displacement of ft to another side (eg: from duodenum to SI. Possibly occurs when pt coughs or vomits. What to do?
= Aspirate GI contents + measure pH
- Remove displaced tube + insert and verify placement of new tube
- If there is question of aspiration, get chest xray
How to measure length of tube to be inserted in pediatrics?
Nose-ear-mid umbilicus better for neonates + children then nose-ear-xyphoid
Is child typically sent to xray to verify tube placement?
What other routine procedure is not recommended in peds?
Special consideration regarding insertion in pediatrics (has to do with heart rate)
No, not routine because of radiation risk
Routine flushes not recommended
Look for vagal stimulation (evidenced by decreased HR)
Special geri consideration for tube insertion?
Ensure adequate lubrication of tube d/t decreased secretions
How frequently is verification of tf placement usually done (asirating for pH)
+ before administering meds + feed
(or depending on patient condition)
Dislocation of the tube upwards can increase risk of?
What different ways are used to determine tip location of feeding tubes?
Are results of pH reliable?
1) Monitor external length of tube + observe the appearance, volume, and pH of fluid aspirated though it
2) Testing pH of aspirate at the bedside
3) repeat xray if any doubt about movement of tf
* Results of pH offers some info but not reliable during continuous feeds + should be used in combo with other methods and careful assessment of pt in the clinical setting.
How does colour help to indicate tip position?
Most intestinal aspirates stained by bile to distinct yellow colour, gastric are not
(However if you look at the pictures in p+p p. 783 it seems to indicate otherwise...)
Do you inject air into the ttube feed prior to aspirating to listen for tip position?
No - listening to air instilled through the tube in unreliable
(Stephen said he still does this sometimes but you neeed a well trained ear and not typically used now)
What conditions increase risk for spontaneous tube migration or dislocation?
- altered LOC/agitation
- Vomiting, coughing
- Nasotracheal suction
What to check on patient prior to aspirating (as another way of checking placement)?
Observe external portion of tube to see if ink mark still at mouth or naris
For intermittently tube fed patients, when should checking tube site through aspiration be done?
Immediately before each feeding or med (as this will lead to aspiration if tube is displaced!)
Do you aspirate for pH checks while a tube feed is infusing?
Perry + Potter says that according to some protocol you'll need to stop the infusion a few hours prior for an accurate reading.
It also says you don't usually interrupt a continuous feed to do this pH checking...only be doing so if is being stopped for some other procedure.
Wait to verify placement at least ____hrs after mediacation admin by tube or mouth.
Procedure for aspirating for pH to check placement of tf
- inject 30mL air in 60mL syringe
- Draw back 5-10mL gastric contents SLOWLY
- Gently mix aspirate in syringe
- Expel few drops into clean medicine cup
- dip pH strip by dipping or applying a few drops
- Compare colour to chart
- IRRIGATE tube
Why inject air prior to aspirating?
Why 60mL syringe?
- Burst of air aids in aspirating fluid more easily
- Small syringe generates unnecssary pressure in tube
What can be helpful to do if aspirating fluid is difficult?
Get patient to reposition side to side
In some cases more than one bolus of air may be necessary
Why aspirate slowly?
Using too small of a syringe or drawing back too quickly may cause tube to collapse
Is it typically harder to aspirate from a small intestine or stomach placement tf?
When might gastric contents be bile stained?
If intestinal contents refluxed into stomach
What is the normal pH of a patient that has fasted for at least 4 horus
Pt with continuous tube feed?
What about from the small intestine?
Usually 5.0 or less
Continuous tf may have ph of 5.0 or higher
SI: pH >6.0
gastric pH paper should have a range of what?
0 to 11.0
pH reading of ___ of less is reliable indicator of stomach placement
5.0 or less
pH of pleural fluid from tracheobronchial tree generally?
WHat to do if you can't aspirate after several attempts?
If has been confirmed by xray to be indesired position and there are no risk factors for tube dislocation, monitor external lengtth + watch pt for evidence of resp distress
What to do if: red or brown colouring (coffee grounds) of fluid aspirated from ft indicates new or old blood in GI tract
If colour not r/t mediactions recently administered, notify hc provider
What to do if pt develops severe resp distress (dyspnea, decreased sats) as results of aspiration?
STop any enteral feedings
Notify hc provider
Obtain CXR as ordered