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Insertion of Enteral Feeding Tubes :

Insertion of Enteral Feeding Tubes Nasoenteral insertion of a gastric feeding tube is the simplest and most often used method of tube feeding. It is used as a temporary measure for clients who are expected to resume oral feeding. Nasogastric intubation refers to insertion of a tube through the nostril into the stomach; Nasoduodenal or nasojejunal intubation allows nasal access to the duodenum and jejunum; it is done with a longer tube and decrease patient the risk of vomiting and aspiration SONGOMA JM ;MUHAS BscN ;2O11 2 Friday, April 13, 2012

Enterostomy (gastrostomy, jejunostomy):

Enterostomy (gastrostomy, jejunostomy) Enterostomy is the surgical creation of an artificial fistula (gastrostomy, jejunostomy) in the intestines by incision the abdominal wall. Tube enterostomies can be placed at various points along the GI tract and are performed when long-term tube feeding is anticipated or when obstruction makes nasal intubation impossible. SONGOMA JM ;MUHAS BscN ;2O11 3 Friday, April 13, 2012

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Inserting a Nasogastric Tube :

Inserting a Nasogastric Tube Purposes - To administer tube feedings and medications to clients unable to eat by mouth or swallow a sufficient diet without aspirating food or fluid into the lungs SONGOMA JM ;MUHAS BscN ;2O11 7 Friday, April 13, 2012


cont To establish a means for suctioning stomach contents to prevent gastric distention, and vomiting. - To remove laboratory contents for laboratory analysis - To lavage (wash) the stomach in case of poisoning or overdose of medication SONGOMA JM ;MUHAS BscN ;2O11 Special Considerations Friday, April 13, 2012

Special Considerations:

Special Considerations • Monitor patient often for coughing, movement, or attempts to the nasogastric (NG) tube, which can cause tracheobronchial aspiration during enteral feedings. • If the patient is on a pump, monitor often and do not exceed 40 psi because excessive pressure can cause the tubing to rupture. • In patients with endotracheal or tracheotomy tubes, check cuff inflation. If deflated, inflate and maintain at least 30 to 60 minutes after feeding to prevent aspiration. SONGOMA JM ;MUHAS BscN ;2O11 9 Friday, April 13, 2012

special consideration:

special consideration Elderly Patient • Check level of consciousness. • Check for aspiration. • Place in Fowler’s position (30-45 degrees) before and after feeding, to prevent aspiration. SONGOMA JM ;MUHAS BscN ;2O11 10 Friday, April 13, 2012


Cont.. Pediatric Patient • Make sure children are in high Fowler’s or upright position during and after feeding to prevent aspiration. • Hold and rock the infants and children if possible during the feeding. • Give a pacifier to an infant during the feeding to meet developmental needs. • Burp or bubble infants at intervals during the feeding and after. • Position an infant in a prone or side-lying position for at least an hour following the feeding to prevent aspiration. SONGOMA JM ;MUHAS BscN ;2O11 11 Friday, April 13, 2012


RELEVANT NURSING DIAGNOSES ● Altered nutrition: less than body requirements, related to anorexia, failure to thrive, or surgery ● Ineffective infant feeding pattern related to premature birth and underdevelopment of major body systems ● Self-care deficit related to dysphasia and impaired physical mobility ● Risk for aspiration related to impaired swallowing SONGOMA JM ;MUHAS BscN ;2O11 12 Friday, April 13, 2012

Equipment :

Equipment Large or small bore tube (plastic or rubber) Solution basin filled with warm water (if plastic tube is used) or ice (if rubber tube is used) Adhesive tape (2.5 cm wide) Disposable gloves Water soluble lubricants Facial tissues Glass of water and drinking straw or medication cup with water SONGOMA JM ;MUHAS BscN ;2O11 13 Friday, April 13, 2012


Equipments 20 to 50 ml syringe with an adaptor Basin Stethoscope Clamp (optional) Suction apparatus (if required) Gauze square or plastic specimen bag and elastic band Safety pin and elastic band Infant seat, towel, or pillow SONGOMA JM ;MUHAS BscN ;2O11 14 Friday, April 13, 2012


Equipment Restrain or hand mitts (for infants and young children) 5-mL or 12 mL, syringe SONGOMA JM ;MUHAS BscN ;2O11 15 Friday, April 13, 2012

Procedure :

Procedure 1. Explain the procedure to the patient. The passage of tube is not painful but is unpleasant. 2. Position the patient in a high fowlers position, if health permits to support head on pillow. 3. In infant, place in infant seat or with rolled towel or pillow under the head and shoulders. 4. Place the towel across the chest. A diaper can be used for an infant. SONGOMA JM ;MUHAS BscN ;2O11 16 Friday, April 13, 2012


Cont.. 5. Ask the client to hyperextend the head, and using a flash light observe the intactness of the tissue of the nostrils. 6. Examine the nares for any obstructions or deformities by asking the client to breath through one nostril while occluding of the other. 7. Select the nostril that has the greater airflow. 8. Obstruct one of the infant’s nares, and feel for air passage from the other. 9. If a rubber tube is being used, place it on ice. SONGOMA JM ;MUHAS BscN ;2O11 17 Friday, April 13, 2012


Continue… 10. Determine how far to insert - Use the tube to mark off the distance from the tip of the client’s nose to the tip of the ear lobe and from the tip of the ear lobe to the tip of the sternum. This length approximate the distance from the nares to stomach. - For infants and young children, measure from the nose to the tip of the ear lobe and then to the xiphoid process. - Mark this length with adhesive tape, if the tube does not have marking SONGOMA JM ;MUHAS BscN ;2O11 18 Friday, April 13, 2012

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Cont.. 11. Lubricate the tip of the tube well with water solution lubricant or water to ease insertion. 12. Insert the tube with its natural curve toward the client in to the selected nostril. Ask the client to hyper extend the neck, and gently advance the tube toward the nasopharynx. Do not hyper-extend or hyper -flex an infant neck 13. Direct the tube along the floor of the nostril and toward the ear on that side. 14. If the tube meets resistance, withdraw it, rubricate it and insert it in the other nostril. (The tube should never be forced against resistance) SONGOMA JM ;MUHAS BscN ;2O11 21 Friday, April 13, 2012

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Cont… 18. As certain correct placement of the tube: - Aspirate stomach content, and check their acidity. - Ascultate air insufflations' - If the signs do not indicate placement in the stomach, advance the tube 5 cm, and repeat the test - For the tube that are to be placed in to the duodenum or jejunum, advance the tube 5 to 7.5 cm per hour until x-ray study confirms its placement. SONGOMA JM ;MUHAS BscN ;2O11 23 Friday, April 13, 2012


Cont.. 19. Secure the tube by taping it to the bridge of the client’s nose - Cut 7.5 cm of tape, and split it length wise at one end, leaving 2.5 cm tab at the end - Place the tape over the bridge of the client’ nose and bring the split ends under the tubing and backup over nose SONGOMA JM ;MUHAS BscN ;2O11 24 Friday, April 13, 2012

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Cont… 20. Attach the tube to the suction source or feeding apparatus as ordered, or clamp the end of the tubing. 21. Secure the tube to the client’s gown. Loop an elastic band around the end of the tubing, and attach the elastic band to the gown with a safety pin or attach a piece of adhesive tape to the tube, and pin the tape to the gown. 22. Document relevant information, means by which correct placement was determined and client response SONGOMA JM ;MUHAS BscN ;2O11 28 Friday, April 13, 2012


Cont.. 23. Establish a plan for providing daily nasogastric tube care - Inspect the nostril for discharge and irritation - Clean the nostril and tube with moistened cotton tipped applicators - Apply water-soluble lubricant to the nostril if it appears dry or encrusted. - Change the adhesive tape ad required - Give frequent mouth care 24. If suction is applied, ensure that the patency of both the nasogastric and suction tubes in maintain SONGOMA JM ;MUHAS BscN ;2O11 29 Friday, April 13, 2012


Cont… 25. Document all relevant information: - Type of tube inserted - Data and time of tube insertion - Type of suction used Colour and amount of gastric content SONGOMA JM ;MUHAS BscN ;2O11 30 Friday, April 13, 2012


cont Five minutes break SONGOMA JM ;MUHAS BscN ;2O11 31 Friday, April 13, 2012


NASOGASTRIC TUBE FEEDING Before commencing nasogastric feeding, determine the type amount, and frequency of feedings. Purposes - To restore or maintain nutritional status - To administer medications SONGOMA JM ;MUHAS BscN ;2O11 32 Friday, April 13, 2012


Equipment - Correct amount of feeding solution - Pacifier - 20 to 50 mL syringe with an adapter- Emesis basin - Bulb syringe (for an intermittent feeding) - Calibrated plastic feeding bag and a drip chamber, which can be attached to the tubing or - Pre-filled bottle with a drip chamber, tubing, and a flow regulator clamp. - Measuring container from which to power the feeding (if using bulb syringe) Water at room temperature SONGOMA JM ;MUHAS BscN ;2O11 33 Friday, April 13, 2012


Procedure/Intervention 1. Prepare the client and the feeding - Explain the patient about the feeding - Provide privacy - Position the patient in Fowler’s position in bed or sitting position in a chair - Position a small child or infant in your lap, and provide a pacifier during feeding 2. Assess tube placement. Attach the syringe to the open end of the tube, aspirate alimentary secretions. Check the PH. SONGOMA JM ;MUHAS BscN ;2O11 34 Friday, April 13, 2012


Cont… 3. Assess residual feeding contents - Aspirate all the stomach contents, and measure the amount prior to administering the feeding. If 50 mL or more undigested formula is withdrawn in adults, or 10 ml or more in infants, check with the nurse in charge before proceeding. - Reinstill the gastric contents in to the stomach if this is the agency or physician’s practice. Remove the syringe bulb or plunger, and pour the gastric contents via the syringe in to the nasogastric tube. SONGOMA JM ;MUHAS BscN ;2O11 35 Friday, April 13, 2012


Cont… 4. Administer the feeding Before administering feeding: a) Check the expiration date of the feeding b) Warm the feeding to room temperature Bulb syringe - Remove the bulb from the syringe, and connect the syringe to a pinched or clamed nasogastric tube - Add feeding to the syringe barrel - Permit the feeding to flow in slowly at the prescribed rate. Raise or lower the syringe to adjust the flow as needed. Pinch or clamp the tubing to stop the flow for a minute if the client experiences discomfort. SONGOMA JM ;MUHAS BscN ;2O11 36 Friday, April 13, 2012


Cont… Feeding Bag - Hang the bag from an infusion pole about 30 cm above the tube’s point of insertion in to the client - Clamp the tubing, and add the formula to the bag, if it is not pre-filled. - Open the damp, run the formula through the tubing, and reclamp the tube. - Attach the bag to the nasogastric tube and regulate the drip by adjusting the clamp to drop factor on bag. SONGOMA JM ;MUHAS BscN ;2O11 37 Friday, April 13, 2012


Cont… 5. Rinse the feeding tube immediately before all the formula has run through the tubing: - Instill 60 mL of water the feeding tube - Be sure to add the water before the feeding solution has drained from the neck of a bulb syringe or from the tubing of an administration set. Before adding water to a feeding bag or prefilled tubing set, first clamp and disconnect both feeding and administration tubes. 6. Clamp and cover the feeding tube - Clamp the feeding tube before all of the water is instilled - Cover the end of the feeding tube with gauze held by an elastic band SONGOMA JM ;MUHAS BscN ;2O11 38 Friday, April 13, 2012


Cont.. 7. Ensure client comfort and safety - Pin the tubing to the clients gown - Ask the client to remain sitting upright in Fowler’s position or in slightly elevated right lateral position for at least 30 minutes. 8. Dispose of equipment appropriately - If the equipment is to be reused, wash with soap and water so that it is ready for reuse. - Change the equipment every 24 hours or according to the agency’s policy. SONGOMA JM ;MUHAS BscN ;2O11 39 Friday, April 13, 2012


Cont… 9. Document all relevant information - Document the feeding, including amount, and kind of solution taken, duration of feeding and assessment of client. - Record the volume of the feeding and water administered on the client’s intake and out put record. 10. Monitor the client for possible problems: - Carefully assess clients receiving tube feeding for problems - To prevent dehydration, give the client supplemental water in addition to the prescribe tube feeding as ordered. SONGOMA JM ;MUHAS BscN ;2O11 40 Friday, April 13, 2012

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Measure Intake and Output:

Measure Intake and Output Intake and output measurements are initiated to monitor the client’s fluid status over a 24-hour period . Agency policy relative to I&O may vary with regard to: • The time frames for charting (e.g., every 8 hours versus every 12 hours) • The time at which the 24-hour totals are calculated • The definition of “strict” I&O SONGOMA JM ;MUHAS BscN ;2O11 43 Friday, April 13, 2012


Cont… “Strict” I&O measurement usually involves accounting for incontinent urine, emesis, and diaphoresis and might require weighing soiled bed linens. Don gloves before handling soiled linen. The nurse reviews the client’s 24-hour I&O calculations to evaluate fluid status. Intake should exceed the output by 500 ml to account for insensible body loses. I&O and daily weights are critical components of intervention because these measurements are also used to evaluate the effectiveness of diuretic or rehydration therapy. SONGOMA JM ;MUHAS BscN ;2O11 44 Friday, April 13, 2012


Equipment I&O form at bedside, I&O graphic record in chart Glass or cup Bedpan, urinal, or bedside commode, Graduated container for output, nonsterile gloves SONGOMA JM ;MUHAS BscN ;2O11 45 Friday, April 13, 2012


procedure 1. Wash hands. 2. Explain purpose of keeping I&O record to client. Explain that: • All fluids taken orally must be recorded. • Form for recording must be used. • Client must void into bedpan or urinal, not into toilet. • Toilet tissue should be disposed of in plastic lined container, not in bedpan. SONGOMA JM ;MUHAS BscN ;2O11 46 Friday, April 13, 2012

Oral Intake:

Oral Intake 3. Measure all oral fluids in accord with agency policy (e.g., cup = 150 ml, glass = 240 ml). 4. Record time and amount of all fluid intake I the designated space on bedside form (oral, tube feedings, IV fluids). 5. Transfer 8-hour total fluid intake from bedside I&O record to graphic sheet or 24-hour I&O record on client’s chart. 6. Record all forms of intake, except blood and blood products, in the appropriate column of the 24-hour record. 7. Complete 24-hour intake record by adding all 8-hour totals. SONGOMA JM ;MUHAS BscN ;2O11 47 Friday, April 13, 2012


Output 8. Don nonsterile gloves. 9. Empty urinal, bedpan, or indwelling catheter drainage bag into graduated container or commode “hat.” 10. Remove gloves, and wash hands. 11. Record time and amount of output (urine, drainage from nasogastric tube, drainage tube) on bedside I&O record. 12. Transfer 8-hour output totals to graphic sheet or 24-hour I&O record on the client’s chart. 13. Complete 24-hour output record by totaling all 8hours SONGOMA JM ;MUHAS BscN ;2O11 48 Friday, April 13, 2012


APPLICATION: HOME CARE Considerations for Measuring I&O • Elicit client and family member input when selecting household items to be used for intake measurement. • Provide containers for measuring output; adapt the urinary container to home facilities, and include teaching relative to proper washing and storage. • Teach hand washing technique. SONGOMA JM ;MUHAS BscN ;2O11 49 Friday, April 13, 2012


Cont.. • Provide written instructions on what is to be measured. • Provide sufficient I&O forms to last between the nurse’s visits. • Identify the parameters for evaluating discrepancy between the intake and output and for notifying the nurse or health care practitioner. SONGOMA JM ;MUHAS BscN ;2O11 50 Friday, April 13, 2012


References Potter .Perry(2009)Fundamental of Nursing 7 th Patricia, K.Sue,C(2006)Fundamental of Nursing Standard and practice 2rd edition Alano,A(2002) Lecture notes for nursing student ,Basic clinical skills ,EPHTI Rhoads ,J. Meeker , ).Davis’s Guide to clinical nursing .FA Company Philadelphia SONGOMA JM ;MUHAS BscN ;2O11 51 Friday, April 13, 2012



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