TYPES OF FEEDING By: Joaquin P.

Venus III, MD,RN COMMON TYPES OF GASTROINTESTINAL TUBE Tube Feeding Administration Methods Types of Tubes by Administration Gastric Tubes: Nasogastric Lavine (single lumen) Salem sump (double lumen) Blakemore (triple lumen) Gastrostomy for long-term feeding PEG tubes Gastrostomy button Small lumen feeding tubes Tube Feeding Administration Methods Types of Tubes by Administration Intestinal Tubes: Nasoduodenal/nasojejunal: Cantor & Harris tube (Single lumen) Miller-Abbott tube (Double lumen) Jejunostomy tubes for long-term feeding GASTRIC TUBES GASTRIC TUBES Short tubes used to intubate the stomach Tube inserted from nose to stomach

6. Lavacuotor tube- an orogastric tube with a large suction lumen and a smaller lavage/vent lumen - provides continuous suction because irrigating solution enters the small lavage lumen while stomach contents are removed through the large suction lumen - used to remove toxic substances from the stomach 7. Ewalds tube- a reusable single lumen large tube used for rapid one-time irrigation and evacuation Nursing Care of the Patient with a Gastric Tube Patient teaching and preparation Tube insertion Confirming placement Securing the tube Monitoring the patient Maintaining tube function Oral and nasal care Monitoring, preventing, and managing complications Tube removal Gastric Tube: Assessment of Placement The most reliable method to check placement is by radiography, which should be performed after initial placement Assess tube placement every 4 hours and before administering feedings or medications Assess placement by aspirating gastric contents and measuring the pH which should be 4 or less (ph of >6 or indicate intestinal placement) Assess amount, color and appearance of aspirate Inserting 5 to 10 ml of air into the NGT and listening for rush of air over the stomach with a stethoscope (least reliable) Irrigating a Nasogastric Tube Connected to Suction NG tubes can be used to decompress the stomach and to monitor for GI bleeding The tube is usually attached to suction when used for these reasons or the tube may be clamped The tube must be kept free from obstruction or clogging and is usually irrigated every 4 to 8 hours Documentation of NG Tube Irrigation Document assessment of the patients abdomen Record if the patients NG tube is clamped or connected to suction, including the type of suction Document the color and consistency of the NG drainage Record the solution used to irrigate the NG tube and ease of irrigation or any difficulty related to the procedure Record the patients response to the procedure and any pertinent teaching points that were reviewed Gastric Tube: Monitoring and Maintaining Tube Function Feedings and Medications via NGT Check residual volumes every 4 hours before each feeding, and before giving medications Aspirate all stomach contents (residual) and measure amount (>100ml, hold feeding) Notify physician if >200ml of residuals occur in two or more times Reinstill residual feeding to prevent excessive fluid and electrolyte losses and prevent metabolic alkalosis, unless the residual volume appears abnormal Gastric Tube: Monitoring and Maintaining Tube Function Irrigation Perform irrigation every 4 hours to check the patency of the tube Assess placement before irrigating Gently instill 30 to 50 ml of water or NSS depending on agency policy with an irrigation syringe Pull back on the syringe plunger to withdraw the fluid to check patency and repeat if the tube remains sluggish Gastric Tube: Management & Prevention of Complications Diarrhea use fiber-containing feedings

Types of Tubes: Nasogastric tubes Types of Tubes: 1. Levin- a plastic or rubber single-lumen NGT with a solid tip that may be inserted into the stomach via nose or mouth. - Use to remove gastric contents via intermittent suction, drain fluid and gas from stomach or to provide tube feedings 2. Salem Sump- a short double-lumen NGT with an small airvent tube within the large suction tube which prevents mucosal suction damage - used for decompression with continuous suction - maintaining pressure at the distal end of the tube at less than 25mmHg NGT: Salem Sump Tube Air vent is not to be clamped and is to be kept above the level of the stomach If leakage occurs through air vent, instill 30ml of air into the airvent and irrigate the main lumen with NSS 3. Sengstaken-Blakemore tube a three-lumen tube. Two parts inflate an esophageal and gastric balloon for tamponade, and the third is used for gastric suction - this tube does not provide esophageal suction, but a NGT may be inserted in the opposite nares or the mouth and allowed to rest on top of the esophageal balloon reducing the risk of aspiration - used primarily to compress esophageal varicosities Sengstaken-Blakemore Tube 4. Minnesota tube a four-lumen gastric tube. - with an additional lumen for aspirating esophagopharyngeal secretions 5. Weighted Flexible Feeding tube with Stylet- a small lumen feeding tube and access port with irrigation adapter which allows maintenance of the tube without disconnecting the feeding set during lavage

- administer feeding slowly and at room temperature Aspiration- verify tube placement - do not administer feeding if residual is greater than 100 ml (check physicians order and agency policy) - keep the head of the bed elevated - if aspiration occurs, suction prn, assess respiratory rate, auscultate lung sounds, monitor temperature for aspiration pneumonia, and prepare to obtain chest radiograph as ordered Gastric Tube: Management & Prevention of Complications Clogged Tubes- use liquid forms of medication, if possible. Flush the tube with 30 to 50 ml of water or NSS before and after medication administration or bolus feeding. Flush with water every 4 hours for continuous feeding Vomiting- administer feeding slowly, and for bolus feedings make the feeding last for 30 minutes. Measure abdominal girth. Do not allow feeding bag to empty. Do not allow air to enter the tubing. Administer feeding at room temperature. Elevate the head of the bed. Administer antiemetics as prescribed. If client vomits, place client in side lying position Unexpected Situations and Associated Interventions With NG Tube Removal Within 2 hours after NG tube removal, patients abdomen is showing signs of distention Notify physician Physician may order nurse to replace NG tube Epistaxis occurs with removal of NG tube Occlude both nares alternately until bleeding has subsided Ensure that patient is in upright position Document epistaxis in patients medical record Gastric Tube: Tube Removal Ask the client to take a deep breath and hold Remove the tube slowly and evenly over the course of 3 to 6 seconds Coil the tube around the hand while removing it Provide suction at bedside for signs of aspiration Assess lung sounds after tube removal GASTROSTOMY TUBE Gastrostomy A Gastrostomy (a surgical opening into the stomach) is made percutaneously (through/under the skin) using an endoscope (a flexible, lighted instrument) to determine where to place the feeding tube in the stomach and secure it in place with sutures Used as an alternative method of feeding, either temporary or permanent, for clients who have problems with swallowing, ingestion, and digestion Bolus Gastrostomy Feeding by Gravity Gastrostomy Tubes Types of Gastrostomy tubes: PEG Gastrostomy button Stamm Janeway Low-profile gastrostomy device (LPGD) Insertion of the PEG tube Gastrostomy (PEG/Button) Tubes Nursing Process: The Care of the Patient With a Gastrostomy: Assessment Patient knowledge and ability to learn Self-care ability and support Skin condition Nutrition and fluid status Gastrostomy: Collaborative Problems/Potential Complications Wound infection GI bleeding Premature removal of tube

Aspiration Constipation Diarrhea Tube Care and Preventing Infection Proper use of dressing Skin care around the tube Manipulation of the stabilizing disk to prevent skin breakdown Gastrostomy Dressing Gastrostomy: Nursing Interventions Maintain skin integrity - inspect and cleanse skin around stoma frequently and keep deep area dry to avoid excoriation Maintain patency of the gastrostomy tube - assess for residual before each feeding - irrigate tube before and after meals - measure/record any drainage Wiping Gastric Tube Site With Cotton-Tipped Applicators Cleaning Gastrostomy Tube With Soap, Water, and Washcloth Turning or Rotating Guard on Gastrostomy Tube Expected Outcomes When Caring for a Gastrostomy Tube The patient ingests an adequate diet The patient exhibits no signs and symptoms of irritation, excoriation, or infection at the tube insertion site The patient verbalizes little discomfort related to tube placement The patient will be able to verbalize the care needed for the gastrostomy tube PERCUTANEOUS ENDOSCOPIC GASTROSTOMY & GASTROSTOMY BUTTON Percutaneous Endoscopic Gastrostomy (PEG) PEG is a surgical procedure for placing a feeding tube without having to perform an open operation on the abdomen (laparotomy). PEG administration of enteral feeds is the most commonly used method of nutritional support for chronic patients. The procedure involves creating a tract by inserting a tube between the stomach and the anterior abdominal wall. The tube can be inserted endoscopically, surgically or radiologically. Gastrostomy Button A Gastrostomy button is like PEG but is useful for more active patients as it lies flush with the skin thus preventing clothes being snagged. Gastrostomy Button are inserted into tracts that are already well established. Button PEGs Purpose of PEG and Button The aim of is to feed those who cannot swallow. To provide fluids and nutrition directly into the stomach. Advantages of PEG and Button Takes less time Carries less risk Costs less than a classic surgical gastrostomy which requires opening the abdomen. PEG & Button Procedure 1. Local anesthesia (usually lidocaine or other spray) is used to anesthetize the throat. An endoscope (a flexible, lighted instrument) is passed through the mouth, throat and esophagus to the stomach. 3. The doctor makes a small incision (cut) in the skin of the abdomen 4. Pushes an intravenous cannula (an IV tube) or button with the tip of tube and internal crossbar through the skin into the stomach 5. Sutures (ties) it in place.

Making an Incision in the Skin Endoscopic View of the PEG Insertion Ballooning of the PEG Cath tip

- 5 to 10 ml of mercury are injected with a needle (gauge 21 or smaller or balloon may leak) and syringe into the bag prior to insertion of the tube to the small intestine - use to drain secretions and decompress the small intestine Cantor / Harris Tube

Radiographic View of the PEG tube PEG and Gastrostomy Button: Risk Factors Risk of abscess formation or peritonitis Infection at the insertion site Peristomal leaks Tube displacement/removal, tube fracture Gastrocolic fistula, septicemia and necrotizing fasciitis Feeding tubes can block easily if you do not flush them before and after every feed or medication. Colonisation and contamination of the enteral feeding system PEG & Gastrostomy Button: Nursing Care 1. All healthcare workers should be well-trained in PEG tube insertion site care 2. Decontaminate hands before and after handling the tube 3. Treat the site as a surgical wound for the first 48 hours 4. After 48 hours, rotate non-sutured tubes through 360 and push the tube in by 5mm and then pull it back gently daily to prevent infections related to buried bumper syndrome 5. Rotate sutured tubes after removing the suture PEG & Gastrostomy Button: Nursing Care 6. After 48 hours and until the stoma site has healed, the tube should be rotated several times a day to prevent it sticking to the stomach wall. 7. The insertion site should be cleaned as necessary and a wound dressing applied if there is leakage around the tube. 8. Usually after 10-12 days the stoma site has healed and no dressings are necessary. You should follow routine care of washing the stoma daily with soap and water and dry it thoroughly 9. Flush the tube with sterile water (or cooled, boiled water) before and after administering feeds or medications to prevent blockage and minimize colonization of the tube Types of Tubes: Intestinal Tubes Types of Tubes: Miller-Abbott tube- a long double lumen tube use to drain and decompress the small intestine - one lumen leads to a balloon that is filled with mercury once it is in the stomach - the second lumen is for irrigation and drainage Miller-Abbott Tube Intestinal Tubes: Nursing Implications Assess physicians orders and agency policy for advancement and removal of tube Position client on high-Fowlers while tube is being passed from the nose to the stomach Then place client on right side to facilitate passage of the mercury weights within the tube through the pylorus of the stomach and into the small intestine (duodenum or jejunum) Do not secure the tube to the face with tape until it has reached final placement (may take several hours) in the intestines Intestinal Tubes: Nursing Implications Radiography is performed to verify desired placement Monitor drainage from the tube If the tube becomes blocked, notify the physician, a small amount of air injected into the lumen may be prescribed to clear the tube Assess the abdomen and measure abdominal girth To remove the tube, the mercury and air are removed from the balloon portion of the tube with a 5ml syringe Intestinal Tubes: Nursing Implications The tube is removed gradually (6 inches every hour) as prescribed by the physician Dispose of the mercury in the appropriate manner as per agency policy NASOGASTRIC INTUBATION Purposes of GI Intubation Decompress the stomach Lavage the stomach Diagnose GI disorders Administer medications and feeding Treat an obstruction Compress a bleeding site Aspirate gastric contents for analysis Indications for a Nasogastric Tube Receive nutrition through a tube feeding using the stomach as a natural reservoir for food Decompress or drain unwanted fluid and air from the stomach Monitor and compress bleeding site in the gastrointestinal (GI) tract Remove undesirable substances (lavage), such as poisons Help treat an intestinal obstruction Diagnose GI disorders by aspirating gastric contents for analysis Analysis of GI Aspirates Gastric aspirates cloudy and light green, tan or off-white, or bloody or brown Intestinal aspirates clear and yellow to bile color (dark green) Pleural aspirates tan or of white mucus, pale yellow and serous (indicating blood) ENTERAL FEEDINGS (GAVAGE)

PEG & Gastrostomy Button: Nursing Care 10. Check the position of feeding tubes regularly and before giving a feed 11. Change tubes according to local policy and the manufacturers instructions 12. Provide follow-up training and ongoing support to patients and carers for the duration of discharge/home enteral feeding

INTESTINAL TUBES Intestinal Tubes: Description Passed nasally into the small intestine The tube may be used to decompress the bowel or to remove intestinal contents The tube enters the small intestine through the pyloric sphincter because of the weight of a small bag of mercury on the tube tip at the end Types of Tubes: Nasogastric Tubes Types of Tubes: Cantor and Harris tube- a single-lumen long tube with a small inflatable bag at the distal end

Enteral Feeding ( Gastric Gavage) Purpose: to provide feeding to administer medications to administer supplemental fluids for decompression Advantages of Enteral Feeding Meets nutritional requirements when oral intake is inadequate or not possible, and the GI tract is functioning Advantages: Safe and cost-effective Preserves GI integrity Preserves the normal sequence of intestinal and hepatic metabolism Maintains fat metabolism and lipoprotein synthesis Maintains normal insulin and glucagon ratios Enteral Feeding: Contraindications Diffused peritonitis Intestinal obstruction that prohibits normal bowel functioning Intractable vomiting 2 paralytic ileus Severe diarrhea Used in Caution in Patients with: Severe pancreatitis Enterocutaneous fistulae GI ischemia Types of Enteral Tube Feedings 1. Continuous feeding An external feeding pump is needed to regulate the flow of formula 2. Intermittent feedings Delivered at regular intervals using gravity for instillation Feeding pump to administer the formula over a set period of time May be given as a bolus, using a syringe to instill the formula quickly in one large amount Enteral Tube Feeding Administration Methods Methods of Administration 1. Intermittent Bolus feedings - a bolus resembles a normal meal feeding patterns. Administration consists of 300 to 400ml of formula given over a 30 to 60 minute period every 3 to 6 hours via infusion pump Continuous infusion - administered continually for 24 hours. An infusion pump regulates the flow Nasoenteric Feeding by Continuous Controlled Pump Enteral Tube Feeding Administration Methods Methods of Administartion 3. Cyclic Feeding- feeding is administered in the daytime or the night time for 8 to 16 hours. An infusion pump regulates the flow. Feedings at night allow for more freedom during the day 4. Intermittent Gravity Drip- an intermittent bolus feeding using a 50 or 60 ml asepto syringe with the plunger removed Bolus Gastrostomy Feeding by Gravity Enteral Feeding Assessment Nutritional status and nutritional assessment Factors or illnesses that increase metabolic needs Hydration and fluid needs Digestive tract function Renal function and electrolyte status Medications that affect nutrition intake and function of the GI tract Compare the dietary prescription to the patients needs. Administering Tube Feeding (Gastric Gavage)

PROCEDURE: Assist the client to a fowlers position in bed or sitting position in a chair , or slightly elevated right side lying position. Assess tube placement patency Assess residual feeding content - To assess absorption of the last feeding. If residuals is 50-100 ml or more verify if the feeding will be given Administering Tube Feeding (Gastric Gavage) Introduce feeding slowly. - To prevent flatulence, crampy, pain or reflex vomiting Height of feeding is 12 inches above the tubes point of insertion into the client Instill 60 ml of water into NGT after feeding. - To cleanse the lumen of the tube Clamp the NGT before all of the feeding or water is instilled Administering Tube Feeding (Gastric Gavage) 8. Ask the client to remain in fowlers position or slightly elevated right lateral position for at least 30 mins - To prevent potential aspiration of feeding 9. Do after-care of equipment 10. Make relevant documentation Collaborative Problems/Potential Complications with Enteral Feeding Diarrhea Nausea and vomiting Gas/bloating/cramping Dumping syndrome Aspiration pneumonia Tube displacement Tube obstruction Nasopharyngeal irritation Hyperglycemia Dehydration and azotemia Maintaining Nutrition Balance and Enteral Tube Function Change the feeding container and tubing every 24 hours Check the expiration date on the formula before administering Shake the formula well before inserting into container Always assess placement of the tube before feeding Always assess bowel sounds; do not administer any feedings if bowel sounds are absent Add a drop of methyline blue to the feeding on clients with ET or tracheal tube. If blue gastric contents appear in tracheal secretions, suspect a Tracheoesophageal fistula or aspiration Maintaining Nutrition Balance and Enteral Tube Function Administer feeding at prescribed rate and method and according to patient tolerance. Measure residual prior to intermittent feedings and every 4-8 hours during continuous feedings. Administer water before and after each medication and each feeding, before and after checking residual, every 4 to 6 hours, and whenever the tube feeding is discontinued or interrupted. Do not mix medications with feedings. Use a 30-mL or larger syringe. Maintain delivery system as required. To avoid bacterial contamination, do not hang the feeding bag more than 4 hours of feeding in an open system. Maintaining Normal Bowel Elimination with Enteral Feeding Selection of TF formula: consider fiber, osmolality, and fluid content Prevent contamination of TF: maintain closed system, do not hang more than 4 hours of TF in an open system. Maintain proper nutritional intake. Assess for reason for diarrhea and obtain treatment as needed.

Administer TF slowly to prevent dumping syndrome Avoid cold TF Enteral Feeding: Reduce Risk for Aspiration Elevate HOB at least 30-45 degrees during and for at least 1 hour after feedings. Monitor residual volumes. Enteral Feeding: Nursing Interventions Promote adequate nutrition - administer feeding with client in high-Fowlers and keep head of bed elevated for 30 minutes after meals to prevent regurgitation - maintain feeding at room temperature - weigh client daily Enteral Feeding: Nursing Interventions Promote adequate nutrition - ensure the prescribed amount of feeding be given within prescribed amount of time - monitor I & O until feedings are well tolerated - monitor for signs of dehydration Enteral Feeding: Nursing Interventions Maintain hydration by supplying additional water and assessing for signs of dehydration. Promote coping by support and encouragement; encourage self-care and activities. Patient teaching Medications via NGT or Gastrostomy Tube Crush medications or use elixir forms of medications Ensure that the medication ordered can be crushed or that the capsule can be opened Dissolve crushed medication or capsule contents in 5 to 10 ml of water Check placement and residual before instilling medications Medications via NGT or Gastrostomy Tube Draw up the medication into a catheter tip syringe, clear excess air, and insert medication into the tube Flush with 30 to 50 ml of water NSS Clamp the tube for 30 to 60 minutes depending on agency policy Expected Outcomes When Assisting a Patient with Enteral Feeding The patient consumes 50% to 60% of the contents of the meal tray The patient does not aspirate during or after the meal The patient expresses contentment related to eating as appropriate TOTAL PARENTERAL NUTRITION A. DESCRIPTION: Supplies necessary nutrients via the veins by providing carbohydrates in the form of dextrose, fats in special emulsified form, proteins in the form of amino acids, vitamins, minerals and water Prevents subcutaneous fat and muscle protein from being catabolized by the body for energy TOTAL PARENTERAL NUTRITION B. INDICATIONS FOR TPN: 1. Clients whose gastrointestinal tracts are severely dysfunctional or nonfunctional and are unable to process nutrients 2. Clients who can take some oral nutrition, but not enough to meet the needs of the body 3. Clients with multiple gastrointestinal surgeries, gastrointestinal trauma, severe intolerance to enteral feedings or intestinal obstructions or who need to rest the bowel for healing 4. Clients with acquired immunodeficiency syndrome, cancer, or malnutrition or clients receiving chemotherapy

C. COMPONENTS Carbohydrates in the form of glucose, with ranges from 5% glucose solution for peripheral parenteral nutrition to a 50% to 70% glucose (hypertonic) solution for central parenteral nutrition. Provides 60 to 70% of caloric (energy) needs Amino Acids provides 3% to 15% of the total calories Lipids (fat emulsion) provides 30% of caloric (energy) needs Vitamins Minerals and trace elements Water Electrolytes Insulin may be given because of high concentration of glucose solution in TPN Heparin to reduce the buildup of a fibrinous clot at the catheter tip TPN Preparation TPN Preparation > the pharmacist will usually add 500 ml of a dextrose solution to 500 ml of an amino acid solution > Dextrose solutions are available as 10, 30, 50, and 70% solutions--when mixed with the amino acid solution the final concentration of the TPN would be 5, 15, 25% and 35% respectively D. 2 TYPES OF IV SITES Central Parenteral Nutrition (CPN) central venous access when client requires a larger concentration of carbohydrates (hypertonic) subclavian or internal jugular veins are used when TPN is a short-term intervention (less than 4 weeks) TPN is anticipated for an extended period of time (greater than 4 weeks), a more permanent catheter such as a peripherally inserted central catheter line, a tunneled catheter or an implanted vascular access device TPN Administration: Central vs Peripheral Peripheral Parenteral Nutrition (PPN) Administered through peripheral vein - For short periods (5 to 7 days) and when the client needs only small concentrations of carbohydrates, fats, and proteins. (isotonic and mildly hypertonic) Used to deliver isotonic or mildly hypertonic solutions. Up to 10% dextrose Avoid delivery of highly hypertonic solutions which can cause sclerosis, phlebitis, or swelling Catheter Types Non-tunneled TPN ADMINISTRATION E. FILTERS TPN must be administered through tubing with an in-line filter to remove crystals from the solution A 0.22 um filter is sufficient for administering solutions without lipid additives Lipids are administered through separate tubing attached below the filter of the main IV administration because particles in the fat emulsion are too large to pass through filters If the parenteral nutrition has lipids added to it, a 1 to 2 um filter or a larger filter should be used Filters F. LIPIDS (FAT EMULSION)

Lipids are given in an isotonic solution that can be administered through the peripheral vein Correct fatty acid deficiency Fat emulsions are prepared from soybean oil, the primary components are linoleic, oleic, palmitic, linoleic, and stearic acids Nursing Interventions: Examine bottle for separation of emulsion into layers or fat globules or for the accumulation of froth; if observed do not use it and return the solution to the pharmacy Do not put additives into the fat emulsion solution Lipids (Fat Emulsion) F. LIPIDS (FAT EMULSION) 3. Do not use an intravenous (IV) filter because particles in the fat emulsion are too large to pass through filters 4. If the fat emulsion has been added to the parenteral nutrition solution, a 1.2 um filter or a larger filter should be used to allow the fat emulsion to pass through 5. Use vented IV tubing because the solution is supplied in a glass container for administration 6. Infuse solution initially at 1ml/min, monitor vital signs every 10 minutes, and observe for adverse reactions for the first 30 minutes of the infusion; if signs of an adverse reaction occur, stop the infusion and notify the physician F. LIPIDS (FAT EMULSION) 7. Signs of an Adverse Reaction to Lipids: a. Chest and back pain g. Flushing b. Chills h. Headache c. Cyanosis i. Nausea and vomiting d. Diaphoresis j. Pressure over the eyes e. Dyspnea k. Thrombophlebitis f. Fever l. Vertigo 8. If no adverse reaction occurs, adjust flow to prescribed rate 9. Monitor serum lipids 4 hours after discontinuing infusion 10. Monitor liver function tests for evidence of impaired liver function indicating the inability of the liver to metabolize the lipids G. NURSING CONSIDERATIONS 1. Always check the TPN solution with the physicians order to ensure that the prescribed components are contained in the solution 2. To prevent infection and solution incompatibility, IV medications and blood are not given through the TPN line 3. Monitor partial thromboplastin time and prothrombin time for clients receiving anticoagulants 4. Monitor electrolytes, albumin, liver and renal function studies 5. In severely dehydrated clients, the albumin level may drop initially as the treatment restores hydration

H. COMPLICATIONS OF TOTAL PARENTERAL NUTRITION Air embolism Fluid overload Hyperglycemia Hypoglycemia Infection Pneumothorax Complications of TPN P 1.Pneumothorax - parenteral nutrition is not started until correct placement of the catheter has been verified through CXR / negative for pneumothorax 2. Air embolism - if suspected: clamp IV catheter then place patient in left lying position with the head lower than the feet (to trap air in the right side of the heart); then notify MD - for tubing and cap changes - place patient in Trendelenburg position or with the patient in head down (supine position) and turned to the opposite direction (of the insertion site); this increases the intrathoracic pressure Complications of TPN 3. Infection > use strict aseptic technique - high concentration of glucose makes it a good medium for bacterial growth > change TPN solution q 12 to 24 hrs > change IV tubing q 24 hrs > change dressing q 48 hrs > if with signs of infection: - remove IV line and restart at a different site - remove tip of catheter and send to lab for culture - prepare client for blood culture 4. Fluid overload > TPN always delivered via electronic infusion device > never increase infusion rate just to catch up if infusion lags behind > monitor weight daily (ideal wt. gain - 1 to 2 lbs/wk) Complications of TPN 5. Hypergl ycemia - begin infusion at a slow rate (40 to 60ml/hr) - monitor glucose q 4-6hrs - administer regular insulin 6. Hypogl ycemia - gradually decrease infusion rate when discontinuing TPN - when infusion of hypertonic glucose is stopped, give 10% dextrose and maintain for 1 - 2 hrs to prevent hypoglycemia - assess glucose 1 hr after discontinuing TPN I. HOME CARE INSTRUCTIONS 1. Teach care giver how to administer and maintain total parenteral nutrition fluids 2. Teach caregiver how to change a sterile dressing 3. Obtain a daily weight at the same time of day in the same clothes 4. Stress that a weight gain of more than 3 lb per week may indicate excessive fluid intake and should be reported 5. Monitor the blood glucose level and report abnormalities immediately 6. Check for signs and symptoms of infection, thrombosis, air embolism, and catheter displacement I. HOME CARE INSTRUCTIONS 7. Instruct in the importance of reporting signs and symptoms of complications

G. NURSING CONSIDERATIONS 6. With severely malnourished clients, monitor for refeeding syndrome (a rapid drop in potassium, magnesium, and phosphate serum levels) 7. Abnormal liver function values may indicate intolerance to or an excess of fat emulsions or problems with metabolism with glucose and protein 8. Abnormal renal function tests may indicate an excess of amino acids 9. TPN solutions should be stored under refrigeration and administered within 24 hours from the time that they were prepared (remove from refrigerator 0.5 to 1 hour before use) 10. TPN solutions that are cloudy or darkened should not be used and should be returned to the pharmacy TPN Chart

8. Symptoms of an air embolus should be taught to another person in the clients home 9. For symptoms of thrombosis the client should report edema of the arm or at the catheter insertion site, neck pain, and jugular vein distention 10. Leaking of fluid from the insertion site or pain or discomfort as the fluids are infused may indicate displacement of the catheter; this must be reported immediately The End GASTRIC LAVAGE Gastric Lavage Is the aspiration of stomach contents and washing out of the stomach by means of a large bore gastric tube Gastric Lavage Contraindicated After acid or alkali ingestion Seizure After ingestion of hydrocarbon or petroleum distillates Dangerous after ingestion of strong corrosive agent Gastric Lavage Purpose: For urgent removal of ingested substance to decrease systemic absorption To empty the stomach after endoscopic procedure To diagnose gastric hemorrhage and to rest hemorrhage. Gastric Lavage Equipment Large bore levin tube or large bore ewald tube Large irrigating syringe with adapter Large plastic funnel with a adapter to fit tube Water soluble lubricant Tap water or appropriate antidote [ milk, saline solution, sodium bicarbonate solution, fruit juice, activated charcoal] Container for aspirate Suction apparatus Container for specimen Stethoscope Gastric Lavage Skill / Step Remove dentures and inspect oral cavity for loose teeth Measure the distance between the bridge of the nose and the xiphoid process. Mark the tube with indelible pencil or tape

Pass the tube orally while keeping the patients head in a neutral position. Pass tube with adhesive marking or about 50 cm ( 20 in). Encourage patient to swallow to assist with passage of tube . Then lower the head of the stretcher or bed. Have standby suction available RATIONALE This position decreases passage of gastric contents into the duodenum during lavage The depth of insertion of the tube varies according to the size of the patient. If the tube enters the trachea instead of the esophagus, the patient will experience coughing, dyspnea, stridor and cyanosis. (+) Confirmation by X-ray Gastric Lavage Skill / Step Aspirate the stomach contents with the syringe attached to the tube before instilling water or an antidote. Save specimen for analysis. Ensure correct placement before instillation Remove the syringe. Attached the funnel to the end of the tube, or use a 50 ml syringe to instill solution in the gastric tube. The volume of fluid placed in the stomach should be small. RATIONALE Aspiration is carried out to determine that the tube is in the stomach and to remove the stomach contents. (+) Confirmation by X-ray Overfilling of the stomach may cause regurgitation and aspiration or force the stomach contents through the pylorus. Gastric Lavage Skill / Step Elevate the funnel above the patients head and pour 150-200 ml of solution into the funnel Lower the funnel and siphon the gastric contents into the container or connect to suction. Save the sample of the first 2 washing Repeat the lavage procedure until the returns are relatively clear and no particulate matter is seen RATIONALE Gravity allows the solution to flow into the tube The fluid should flow in freely and drain by gravity

Lubricate the tube with water soluble lubricant If comatose, the patient is intubated with a cuffed nasotracheal or ETT before placement of NGT. RATIONALE This will prevent aspiration of teeth This distance is a rule of thumb measurement of the distance the tube must be passed to reached the stomach. This avoid curling and kinking of excess tubing in the stomach. Lubrication eases insertion of the tube A cuffed nasotracheal or ETT decrease the risk of aspiration of gastric content Gastric Lavage Skill / Step Place patient in a left lateral position with the head lowered about 15 degrees Keep the first washing sample isolated from other washing for toxicology analysis This usually requires a total volume of at least 2L; some use 5-20 L Gastric Lavage Skill / Step At the completion of the lavage: The stomach may be left empty An adsorbent [powder form of activated charcoal mixed with water to form a liquid the consistency of thick soup] or Saline cathartic may be instilled in the tube. RATIONALE the stomach is kept empty if no further medication are required.

Activated charcoal reduces absorption by adsorbing ( attaching to its surface) a wide range of substance ; it render poison inaccessible to circulation thereby reducing its toxicity. A cathartic may be given to hasten the elimination of the remaining ingested material Gastric Lavage Skill / Step Pinch off the tube during removal or maintain suction while the tube is being withdrawn. Keep the patients head lower than the body Warn the patient that his stools will turn black from the charcoal RATIONALE Pinching off the tube prevents aspiration and initiation of gag reflex. Keeping patients head lower than the body also helps prevent initiation of the gag reflex. Patient teaching is important to reduce anxiety Gastric suction Gastric suction is perform to empty the contents of the stomach before it passes through the rest of the digestive tract.

D. Administer feeding at room temperature Gastric aspirates has been drained by a nurse prior to feeding. The nurse expects that the drainage will appear: A. cloudy and light green, tan or off-white B. clear and yellow to bile color C. tan or of white mucus, pale yellow and serous with blood D. Any of the above 6. The nurse providing instructions to a client with risk for aspiration who will be discharged to home with self-administered bolus enteral feedings would teach the client to infuse the feeding over: A. 2 to 10 minutes B. 10 to 15 minutes C. 30 to 60 minutes D. 90 to 120 minutes

DOCUMENTATION: Document the following in the patient care record/unit specific flow sheet, or progress notes: - patients tolerance to procedure - procedure performed and results - any complications/difficulties, including nursing action taken - care of tubes - condition of nare every shift - family/caregiver teaching

7. To help prevent hyperglycemia in a client receiving TPN, the nurse would: A. Use an infusion pump B. Administer the solution slowly C. Protect the solution from light D. Keep the infusion at room temperature

8. The nurse planning to irrigate a nasogastric (NG) tube prepares to use: A. Half-strength peroxide B. Sterile water C. Normal saline D. Cold tap water 9. The nurse clarifies that a tube feeding is also called: A. Lavage B. Gavage C. Bougienage D. Foulage 10. The nurse caring for a client who is to undergo the insertion of a PEG tube can best explain how a PEG tube differs from a gastrostomy tube by describing: A. Diameters of the tubes B. Methods of insertion C. Location of the tubes D. Procedures used for feedings Matching Type TYPES OF TUBE: Cantor tube Miller-Abbott Levin Tube SengstakenBlakemore

QUIZ MULTIPLE CHOICE 1. Levin tube is use for the following EXCEPT: A. Remove gastric contents via intermittent suction B. Remove gastric continuous suction C. Drain fluid and gas from stomach D. Provide tube feedings

2. One of the following is a proper nursing care of a client with Salen Sump tube: Air vent is to be clamped Air vent is to be kept at the level of the stomach C. If leakage occurs through air vent, instill 300ml of air into the airvent D. If leakage occurs through air vent, irrigate the main lumen with NSS One of the following is not included as a lumen in SengstakenBlakemore tube: A. Large suction tube B. Gastric aspiration lumen C. Esophageal balloon inflation lumen D. Gastric balloon inflation lumen To prevent vomiting during feeding, the best nursing interventions include the following EXCEPT: A. Side-lying position B. Administer feeding for 30 minutes C. Do not allow air to enter the tubing

A. 4 lumen B. Single lumen gastric tube C. 3 lumen D. Double lumen intestinal tube 15. Minnesota Tube E. Single lumen intestinal tube END OF QUIZ