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Copyright © 2008 Lippincott Williams & Wilkins.

Chapter 36Gastrointestinal Intubation and Special Nutritional Modalities

Chapter 36Gastrointestinal Intubation and Special Nutritional Modalities


Purposes of GI IntubationPurposes 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


Types of TubesTypes of Tubes

• Gastric tubes

– Levin

– Sump

• Enteric tubes


Gastric Sump Tube Gastric Sump Tube


Nursing Care of the Patient with a Nasogastric or Nasoenteric TubeNursing Care of the Patient with a Nasogastric or Nasoenteric 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


Measuring for Nasogastric Tube Insertion Measuring for Nasogastric Tube Insertion


Securing the NG TubeSecuring the NG Tube


Purposes and Advantages of Enteral FeedingPurposes and 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


Tube Feeding Administration MethodsTube Feeding Administration Methods

• Tubes

– Nasogastric or nasoenteral tubes

– Gastrostomy or jejunostomy tubes for long-term feeding

• Methods

– Intermittent bolus feedings

– Intermittent gravity drip

– Continuous infusion

– Cyclic feeding


Bolus Gastrostomy Feeding by GravityBolus Gastrostomy Feeding by Gravity


Nasoenteric Feeding by Continuous Controlled PumpNasoenteric Feeding by Continuous Controlled Pump


Nursing Process: The Care of the Patient Receiving an Enteral Feeding: AssessmentNursing Process: The Care of the Patient

Receiving an 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 patient’s needs.


Nursing Process: The Care of the Patient Receiving an Enteral Feeding: Diagnosis Nursing Process: The Care of the Patient Receiving an Enteral Feeding: Diagnosis

• Imbalanced nutrition

• Risk for diarrhea

• Risk for ineffective airway clearance

• Risk for deficient fluid

• Risk for ineffective coping

• Risk for ineffective therapeutic regimen management

• Deficient knowledge


Collaborative Problems/Potential Complications (See Table 36-3)Collaborative Problems/Potential Complications (See Table 36-3)

• Diarrhea

• Nausea and vomiting

• Gas/bloating/cramping

• Dumping syndrome

• Aspiration pneumonia

• Tube displacement

• Tube obstruction

• Nasopharyngeal irritation

• Hyperglycemia

• Dehydration and azotemia


Nursing Process: The Care of the Patient Receiving an Enteral Feeding: PlanningNursing Process: The Care of the Patient Receiving an Enteral Feeding: Planning

• Major goals may include nutritional balance, normal bowel elimination pattern, reduced risk of aspiration, adequate hydration, individual coping, knowledge of and skill in self-care, and prevention of complications.


Maintaining Nutrition Balance and Tube FunctionMaintaining Nutrition Balance and 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 more than 4 hours of feeding in an open system.


Maintaining Normal Bowel EliminationMaintaining Normal Bowel Elimination

• 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 (See Chart 36-2).

• Avoid cold TF.


Reduce Risk for AspirationReduce Risk for Aspiration

• Elevate HOB at least 30-45 degrees during and for at least 1 hour after feedings.

• Monitor residual volumes.


Other InterventionsOther 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


Gastrostomy TubesGastrostomy Tubes

• Types of tubes:

– Stamm

– Janeway

– PEG

– Low-profile gastrostomy device (LPGD)

• Insertion of the PEG tube


Gastrostomy (PEG) Tubes Gastrostomy (PEG) Tubes


Nursing Process: The Care of the Patient With a Gastrostomy: AssessmentNursing 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


Nursing Process: The Care of the Patient With a Gastrostomy: DiagnosisNursing Process: The Care of the Patient With a Gastrostomy: Diagnosis


• Risk of infection

• Risk for impaired skin integrity

• Ineffective coping

• Disturbed body image

• Risk for ineffective therapeutic regimen management


Collaborative Problems/Potential ComplicationsCollaborative Problems/Potential Complications

• Wound infection

• GI bleeding

• Premature removal of tube

• Aspiration

• Constipation

• Diarrhea


Nursing Process: The Care of the Patient With a Gastrostomy: PlanningNursing Process: The Care of the Patient With a Gastrostomy: Planning

• Major goals include attaining an optimal level of nutrition, preventing infection, maintaining skin integrity, enhancing coping skills, adjusting to changes in body image, acquiring knowledge of and skill in self-care, and preventing complications.


Tube Care and Preventing InfectionTube Care and Preventing Infection

• Proper use of dressing

• Skin care around the tube

• Manipulation of the stabilizing disk to prevent skin breakdown


PEG DressingPEG Dressing


Parenteral NutritionParenteral Nutrition

• A method to provide nutrients to the body by an IV route

• A complex mixture containing proteins, carbohydrates, fats, electrolytes, vitamins, trace minerals, and sterile water is administered in a single container.

• The goals of parenteral nutrition are to improve nutritional status and to attain a positive nitrogen status.


Indications for Parenteral Nutrition Indications for Parenteral Nutrition

• Intake is insufficient to maintain anabolic state.

• Ability to ingest food orally or by tube is impaired.

• Patient is not interested in ingesting or is unwilling to ingest adequate nutrients.

• The underlying medical condition precludes oral or tube feeding.

• Preoperative and postoperative nutritional needs are prolonged.


Nursing Process: The Care of the Patient Receiving Parenteral Nutrition: Assessment

Nursing Process: The Care of the Patient Receiving Parenteral Nutrition: Assessment• Assist in identifying patients who are candidates for PN

• Nutrition status

• Hydration status

• Electrolytes

• Signs and symptoms of hypoglycemia/hyperglycemia

– Monitor blood glucose levels.

• Assess for potential complications

– VS including temperature every 4 hours or by protocol


Nursing Process: The Care of the Patient Receiving Parenteral Nutrition: DiagnosisNursing Process: The Care of the Patient Receiving Parenteral Nutrition: Diagnosis


• Risk for infection

• Risk for excess or deficient fluid

• Risk for immobility

• Risk of ineffective therapeutic regimen


Collaborative Problems and Potential ComplicationsCollaborative Problems and Potential Complications

• Pneumothorax

• Clotted or displaced catheter

• Sepsis

• Hyperglycemia

• Rebound hypoglycemia

• Fluid overload


Nursing Process: The Care of the Patient Receiving Parenteral Nutrition: PlanningNursing Process: The Care of the Patient Receiving Parenteral Nutrition: Planning

• Major goals may include attaining an optimal level of nutrition, absence of infection, adequate fluid volume, optimal level of activity, knowledge of self-care, and absence of complications.


Prevention of InfectionPrevention of Infection

• Appropriate catheter and IV site care

• Strict sterile technique for dressing changes

• Wear mask when changing the dressing.

• Assess insertion site.

• Assess for indicators of infection.

• Proper IV and tubing care


Maintaining Fluid BalanceMaintaining Fluid Balance

• Use infusion pump. Flow rate should not be increased or decreased rapidly. If fluid runs out, hang 10% dextrose solution.

• Monitor indicators of fluid balance and electrolyte levels.

• I&O

• Weights

• Monitor blood glucose levels.


Patient Teaching (See Charts 36-5 and 36-6)Patient Teaching (See Charts 36-5 and 36-6)

• Goals and purpose

• Components of PN

• Emergency contact numbers

• Demonstrate use of equipment and how to handle and hang the IV.

• Demonstrate dressing changes.

• Demonstrate how to flush or heparinize the catheter.

• Potential complications and actions to take

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