Slide 1

NUR 141 For this power point presentation, I will concentrate on the following: SKILL 31-1: Inserting & Removing a small-bore nasogastric or Naso-enteric Feeding Tube SKILL 31-2: Verifying Feeding Tube Placement Slide 2 NUR 141: SKILL 31-1 Inserting & removing a small-bore nasogastric or naso-enteric feeding tube Slide 3 ENTERAL NUTRITION NG (NASO-GASTRIC) feeding tubes are often inserted at the bedside, without technologic assistance, in a procedure commonly referred to as blind placement. The most serious complication of NG tube insertion is inadvertent pulmonary intubation. Feeding tubes are positioned into the small bowel to reduce the incidence of pulmonary aspiration of stomach contents. Maintaining & monitoring tube location during feeding and keeping the head-of-bed- elevation at a minimum of 30 degrees (preferably 45 degrees) effectively reduces aspiration & subsequent pneumonia. Lets talk about enteral nutrition! Enteral nutrition, commonly called tube feeding, refers to the delivery of nutritional formulas through a tube that has been placed into the GI tract (Gastro-intestinal tract). Candidates for tube feeding include patients who have adequate digestion and absorption but cannot ingest, chew, or swallow food safely or in adequate amounts. A tube feeding is administered into the stomach or small intestine. Slide 4 SKILL 31-1: INSERTING & REMOVING A SMALL- BORE NASOGASTRIC OR NASOENTERIC FEEDING TUBE Because feeding tubes are soft and flexible, many use a removable guide-wire or stylet to provide stiffness during tube insertion. Although these wires facilitate placement of a tube, they also add to the risk of pulmonary or esophageal injury during insertion. Placement of a feeding tube requires a health care providers order. All candidates for NG or naso-enteric tube placement require an assessment of their coagulation status. This is because anticoagulation and bleeding disorders pose a risk for epistaxis during nasal tube placement, the health care provider may order platelet transfusion or other corrective measures before tube insertion. Slide 5 SKILL 31-1: ASSESSMENT: Inserting & Removing a small-bore nasogastric or nasoenteric feeding tube Verified health care providers order for type of tube & enteric feeding schedule. Assess patients knowledge of procedure. Have patient close each nostril alternatively & breathe. Examine each naris for patency & skin breakdown. Review patients medical history (e.g., for basilar skull fracture, nasal problems, nosebleeds, facial trauma, nasal-facial surgery, deviated septum, anticoagulant therapy, coagulopathy). Clinical Decision Point: If a patient is at risk for intracranial passage of the tube, avoid the nasal route. Oral placement or placement under medical supervision using direct visualization is preferable. Insertion of a gastrostomy or jejunostomy tube is another alternative. Assess patients mental status (ability to cooperate with procedure, sedation), presence of cough and gag reflex, ability to swallow, critical illness, and presence of an artificial airway. Slide 6 SKILL 31-1 ASSESSMENT CONTD Clinical Decision Point: Recognize situations in which blind placement of a feeding tube poses an unacceptable risk for placement. Devices designed to detect pulmonary intubation such as CO2 sensors or electromagnetic tracking devices enhance patient safety. Alternatively, to avoid insertion complications from blind placement in high-risk situations, clinicians trained in the use of visualization or imaging techniques should place tubes. Perform physical assessment of the abdomen see next slide for this please. Absent bowel sounds, abdominal pain, tenderness, or distention may indicate medical problems contraindicating feedings. Slide 7 ASSESSMENT OF THE ABDOMEN IMPLEMENTATION: Ask if patient needs to empty bladder or defecate Keep upper chest and legs draped Be sure that the room is warm Have patient lie supine or in a dorsal recumbent position with arms down at sides and knees slightly bent. Place a small pillow under the patients knees Move sheet or blanket to expose are from just above xiphoid process down to symphysis pubis Maintain conversation during assessment except during auscultation. Explain steps calmly & slowly Ask patient to point to tender areas Slide 8 ASSESSMENT OF THE ABDOMEN CONTD Abdominal Assessment: Identify landmarks that divide abdominal region into quadrants. Boundary begins at tip of xiphoid process to symphysis pubis with line crossing & intersecting umbilicus, dividing abdomen into four equal sections. Inspect skin of surface of abdomen for color, scars, venous patterns, rashes, lesions, silvery white striae (stretch marks), and artificial openings (stomas). Observe skin lesions for different characteristics Slide 9 ABDOMINAL ASSESSMENT CONTD If you note bruising, ask if patient self-administers injections, such as insulin, for ex. Inspect contour, symmetry and surface motion of abdomen. Note any masses, bulging, or distention. If abdomen appears distended, note if distention is generalized. Look at the flanks on each side. If you suspect distention, measure size of abdominal girth by placing tape measure under patient and around abdomen at level of umbilicus. Use marking pen to indicate where tape measure was applied. Slide 10 ABDOMINAL ASSESSMENT CONTD To auscultate bowel sounds, place the diaphragm of the stethoscope lightly over each of the four abdominal quadrants. Ask patient not to talk. Listen until you hear repeated gurgling or bubbling sound sin each quadrant (Minimum of once in 5 to 20 seconds). Describe sounds as normal, hyperactive, hypoactive, or absent. Listen 5 minutes over each quadrant before deciding that bowel sounds are absent Slide 11 ABDOMINAL ASSESSMENT CONTD Place the bell of the stethoscope over the epigastric region of the abdomen and each quadrant. Auscultate for vascular (whooshing) sounds. With patient supine, gently percuss each of the four abdominal quadrants systematically. Note areas of tymphany and dullness. To determine if fluid or air is causing distention, percuss for a fluid wave. Ask a colleague to assist by pressing gently and firmly at midline of abdomen. Place your fingertips along both sides of lower abdomen in lumbar region. Thrust quickly into the patients side with your dominant hand, keeping non- dominant hand in place. If fluid is present, you will palpate a fluid wave with the non-dominant hand. Slide 12 ABDOMINAL ASSESSMENT CONTD Ask patient if abdomen feels unusually tight and determine if this is a recent development. With patient sitting, gently but firmly percuss over each CVA (Costo-vertebral Angle) along scapular lines. Use ulnar surface of fist indirectly by placing non-dominant hand flat against CVA & percussing with dominant hand or percuss directly against patients skin. Note if the patient is experiencing any type of pain. Lightly palpate over each abdominal quadrant, laying palm of hand with fingers extended and approximated lightly on abdomen. Keep palm and forearm horizontal. Slide 13 ABDOMINAL ASSESSMENT CONTD The pads of the fingertips should depress the skin no more than 1 cm (1/2 inch) in a gentle dipping motion. Palpate painful areas last. Note muscular resistance, distention, tenderness & superficial masses or organs while observing patients face for signs of discomfort. Note if abdomen is firm or soft to touch. Just below umbilicus and above symphysis pubis, palpate for a smooth, rounded mass. While applying light pressure, ask if patient has sensation of need to void. If masses are palpated, note size, location, shape, consistency, tenderness, mobility & texture. Slide 14 ABDOMINAL ASSESSMENT CONTD This is the end of the assessment for abdominal assessment. There is no video for this, but I found one on you-tube if you would like to review it: http://www.youtube.com/watch?v=xtBXoKdf5MA http://www.youtube.com/watch?v=xtBXoKdf5MA ABDOMINAL ASSESSMENT You can review all of the notes that I presented 100 times, but if you dont practice and watch the above video, you will not be able to correctly perform an abdominal assessment. Slide 15 Now, lets go back to our main skill: SKILL 31-1: Inserting & Removing a Small- Bore Nasogastric or Naso-enteric Feeding Tube Slide 16 SKILL 31-1: INSERTING & REMOVING A SMALL BORE NASOGASTRIC OR NASENTERIC FEEDING TUBE PLANNING: Expected outcomes following completion of procedure: Tube is verified as placed in stomach or intestine. Feeding tube remains patent Patient has no respiratory distress (e.g., increased respiratory rate, coughing, poor color) or signs of discomfort or nasal trauma. Explain procedure to patient, including sensations that will be felt during insertion. By increasing patients cooperation with intubation procedure, you will help lessen their anxiety. Also, explain to patient how to communicate during intubation by raising index finger to indicate gagging or discomfort. Slide 17 SKILL 31-1: IMPLEMENTATION-Contd IMPLEMENTATION: 1. Identify patient using two identifiers (i.e., name & birthday or name & account number) according to agency policy. Compare identifiers with information on patients identification bracelet 2. Perform hand hygiene 3. Position patient upright in a high Fowlers position unless contraindicated. If patient is comatose, raise head of bed as tolerated in semi-Fowlders position with head tipped forward, chin to chest. If necessary have an assistant help with positioning of confused or comatose patients. If patient is forced to lie supine, place in reverse Trandelenburgs position. Slide 18 IMPLEMENTATION CONTD 4. Apply pulse oximeter & measure vital signs. 5. Determine length of tube to be inserted and mark location with tape of indelible ink. A. Measure distance from tip of nose to earlobe to xyphoid process of sternum. 6. Prepare NG or nasoenteric tube for intubation. A. Inject 10 mL of water from 30 to 60 mL. Luer-Lok or catheter-tip syringe into the tube. B. If using stylet, make certain that it is positioned securely within tube. Slide 19 IMPLEMENTATION CONTD Clinical Decision Point: Tip of the tube must reach stomach to avoid the risk for pulmonary aspiration, which occurs when tube terminate in the esophagus. 7. Cut hypoallergenic tape 10 cm (4 inches) long or prepare membrane dressing or other tube fixation device. 8. Apply clean gloves 9. Dip tube with surface lubricant into glass of room-temperature water or apply water-soluble lubricant (see manufacturer directions). Slide 20 IMPLEMENTATION CONTD 10. Explain the step and gently insert tube through nostril to back of throat (posterior nasopharynx). This may cause patient to gag. Aim back & down toward ear. 11. Have patient flex head toward chest after tube has passed through nasopharynx. 12. Encourage patient to swallow by giving small sips of water or ice chips. Advance tube as patient swallows. Swallowing facilitates passage of tube past oropharynx. Distinct tug may be felt as patient swallows, indicating that tube is following expected path. 13. Reemphasize need to mouth breathe and swallow during procedure. 14. When tip of tube reaches carina (approximately 25 to 30 cm (10 to 12 inches) in an adult), stop and listen for air exchange from distal portion of tube. Slide 21 IMPLEMENTATION CONTD Here is a picture of a nurse putting in a feeding tube Please note how the patient is drinking, to help make the tube go down easier. Slide 22 IMPLEMENTATION CONTD 15. Advance tube each time patient swallows until desired length. Clinical Decision Point: Do not force the tube or push against resistance. If patient starts to cough, experiences a drop in oxygen saturation, or shows other signs of respiratory distress, withdraw the tube into the posterior nasopharynx until normal breathing resumes. 16. Check for position of tube in back of throat with penlight & tongue blade. 17. Temporarily anchor tube to nose with a small piece of tape. 18. Keep tube secure & check placement of tube by aspirating stomach contents to measure gastric pH (this will be in Skill 31-2). Slide 23 IMPLEMENTATION CONTD Clinical Decision Point: Insufflation of air into tube while auscultating abdomen is not a reliable means to determine position of feeding tube tip. 19. Anchor tube to patients nose, avoiding pressure on nares. A properly secured tube allows patient more mobility & prevents trauma to nasal mucosa. Mark exit site on tube with indelible ink. Select one of the following options for anchoring: A. APPLY TAPE 1. Apply tincture of benzoin or other skin adhesive on tip of patients nose and allow it to become tacky 2. Remove gloves & split one end of tape lengthwise 5 cm (2 inches). 3. Place intact end of tape over bridge of patients nose. Wrap each of the 5 cm strips in opposite directions around tube as it exits nose. Slide 24 IMPLEMENTATION CONTD B. Apply membrane dressing or tube fixation device: 1. Membrane Dressing: A. Apply tincture of benzoin or other skin protector to patients cheek and area of tube to be secured. B. Place tube against patients cheek & secure tube with membrane dressing, out of patients line of vision. 2. Tube Fixation Device: A. Apply wide end of patch to bridge of nose B. Slip connector around feeding tube as it exits nose. 20. Fasten end of NG tube to patients gown using clip or piece of tape. Do not use safety pins to secure tube to gown. 21. Assist patient to comfortable position. Remove gloves & perform hand hygiene. Slide 25 IMPLEMENTATION CONTD Clinical Decision Point: Leave stylet in place until correct position is verified by x-ray film. Never try to reinsert a partially or fully removed stylet while feeding tube is in place. This can cause perforation of tube and injure the patient. 22. Obtain X-Ray film of chest / abdomen 23. Apply clean gloves & administer oral hygiene. Clean tubing at nostril with washcloth dampened in mild soap & water 24. Remove gloves, dispose of equipment and perform hand hygiene. Slide 26 TUBE REMOVAL 1.Verify health care providers order for type of tube and enteric feeding schedule. 2. Gather equipment: Disposable pad, tissues, clean gloves, disposable plastic bag or receptacle. 3. Explain procedure to patient. 4. Perform hand hygiene. Apply clean gloves. 5. Position patient in high Fowlers position unless contraindicated. 6. Place disposable pad or towel over patients chest. 7. Disconnect tube from feeding administration set if present. Slide 27 TUBE REMOVAL CONTD 8. Remove tape or tube fixation device from patients nose. Unclip tube from patients gown. 9. Instruct patient to take a deep breath and hold it. 10. Kink end of tube securely by folding it oer on itself. 11. Completely withdraw tube by pulling it out steadily and smoothly. Dispose of it into appropriate receptacle. 12. Offer tissues to patient to blow nose. 13. Offer mouth care. 14. Remove gloves; perform hand hygiene. Slide 28 EVALUATION Observe patients response to intubation. Have patient speak. Check vital signs. Option: You may use capnography in critical care settings to determine if tip of tube is in trachea or lung. Confirm X-Ray results with Health care provider. Remove the stylet (if used) after X-Ray film verification of correct placement. Routinely check location of external site marking on the tube and color and pH of fluid aspirated from tube. After removal, assess patients level of comfort. Slide 29 RECORDING & REPORTING, ALONG WITH SPECIAL CONSIDERATIONS Recording & Reporting: Record & report type and size of tube placed, location of distal tip of tube, patients tolerance of procedure and confirmation by x-ray film examination. Record removal of tube & patients tolerance. Report any type of unexpected outcome and the interventions performed. Tube removal: record patients level of comfort. Special Consideration: Teaching: Instruct patient or family caregiver to offer oral hygiene frequently and keep patients lip lubricated. Teach patient or family caregiver to report tension on feeding tube or displacement of tape or tube fixation device; instruct patient or caregiver to stabilize the tube and call for help. Slide 30 END OF SKILL 31-1:Inserting & Removing a Small-Bore Nasogastric or Nasoenteric Feeding Tube This is the end of this skill. Remember, these power-point presentations are meant to HELP YOU.they are not the CURE- ALL! I did go off in a different direction, during this skill, and I discussed how to assess the abdomen. The nursing instructor may or may not ask you this during the testing of your skill, but, if it were me, I would know how to do this! Slide 31 END OF SKILL There is no video provided for this skill in your text-book. I have gone on you-tube and found the one below, for you. Remember though, if you dont go into the skills lab to practice though, you will not pass this skill, no matter how many times you read this presentation or watch the video. Also, remember, this video is provided by me, not the school, so while I tried to pick the best example of this skill for you, remember to follow your book and PRACTICE! Video link for the above skill: (copy & paste!) Name of video: Nasogastric tube insertion, irrigation, removal http://www.youtube.com/watch?v=vVEYfRmrCvQ Slide 32 SKILL 31-2: VERIFYING FEEDING TUBE PLACEMENT Different colors that are aspirated from the stomach Slide 33 VERIFYING FEEDING TUBE PLACEMENT Nurses insert small-bore feeding tubes nasally for intermittent or continuous feeding. It is possible for the tip of a feeding tube to move or migrate into a different location (e.g., from the stomach into the intestine or esophagus, from the intestine into the stomach). Although all tubes should be marked to document correct position, tube dislocation can sometimes occur without any external evidence that the tube has moved. The risk of aspiration of regurgitated gastric contents into the respiratory tract increases when the tip of the tube accidentally dislocates upward into the esophagus. Slide 34 VERIFYING FEEDING TUBE PLACEMENT CONTD Following initial x-ray film verification of correct feeding tube position, you must monitor the tube to ensure that the tube tip remains in the intended site. Based on a patients clinical condition and agency policies, you check feeding tube position at regular intervals (often every 4 to 6 hours) and before administering formula or medications through the tube. ASSESSMENT: 1. Maintained awareness of agency policy and procedures for checking tube placement, did not insufflate air into tube. 2. Identified signs of inadvertent respiratory distress during feeding. 3. Identified conditions that increase the risk of spontaneous tube dislocation. A. Altered level of consciousness, agitation. B. Retching / vomiting / coughing C. Naso-tracheal Suction 4. Observed external portion of tube for movement of ink mark. Slide 35 ASSESSMENT CONTD 5. Reviewed patients medication record for orders for continuous feeding or gastric acid inhibitor or a proton pump inhibitor. 6. Reviewed patients record for history of prior tube displacement. PLANNING: Identify expected outcomes: The expected outcome, following the procedure, would be: The color, pH, and appearance of the gastric aspirated are consistent with initial tube placement. Explained procedure to patient Slide 36 IMPLEMENTATION 1. Identified patient using two identifiers (i.e.; name & birthday or name & account number) according to agency policy. 2. Prepare equipment at patients bedside, performed hand hygiene, applied clean gloves. 3. Verify tube placement at the following times A. For intermittently tube-fed patients; test placement immediately before each feeding and before medications. B. Follow agency policy regarding pH testing for patients receiving continuous tube feeding. C. Wait to verify placement at least 1 hour after medication administered by tube or mouth. Slide 37 IMPLEMENTATION CONTD 4. Draw up 30 mL of air into a 60 mL syringe & attach it to end of the feeding tube. Flush tubing with 30 mL of air before attempting to aspirate fluid. Repositioning patient from side to side is helpful. In some cases more than one bolus of air is necessary. 5. Draw back on syringe slowly and obtain 5 to 10 mL of gastric aspirate. Observe appearance of aspirate. Slide 38 IMPLEMENTATION CONTD 6. Gently mix aspirate in syringe. Expel a few drops into clean medicine cup. Measure pH of aspirated GI contents by dipping pH strip into fluid or by applying a few drops of fluid to strip. Compare color of strip with color on chart provided by manufacturer. A. Gastric fluid from patient who has fasted for at least 4 hours usually has pH range of 5.0 or less. B. Fluid from tube in small intestine or fasting patient usually has a pH of greater than 6.0 A pH reading of 5.0 or less is a reliable indicator of stomach placement, especially when gastric acid inhibitor is not being used. C. A patient with a continuous tube feeding may have a pH of 5.0 or higher. D. pH of pleural fluid from tracheobronchial tree is generally greater than 6.0. Slide 39 IMPLEMENTATION CONTD 7. If after repeated attempts it is not possible to aspirate fluid from a tube that was confirmed by x-ray film to be in desired position and if there are not risk factors for tube dislocation, monitor external length of tube and observe patient for evidence of respiratory distress. 8. Irrigate tube (see Skill 31-3). 9. Remove and dispose of gloves and supplies in appropriate receptacle. Perform hand hygiene. Slide 40 EVALUATION 1. Observe patient for respiratory distress; persistent gagging, paroxysms of coughing, drop in 02 saturation, respiratory patterns (e.g., rate and depth) that are inconsistent with baseline measures. 2. Verify that external length of tube, pH, and appearance of aspirate are consistent with initial tube placement Slide 41 UNEXPECTED OUTCOMES 1. Red or brown coloring (coffee grounds appearance) of fluid aspirated from feeding tube indicates new or old blood, respectively, in GI tract. If color is not related to medications recently administered, notify health care provider. 2. Patient develops severe respiratory distress (e.g., dyspnea, decreased oxygen saturation, increased pulse rate) as a result of aspiration or tube displacement in lung. Stop enteral feedings. Notify health care provider. Obtain chest x-ray film as ordered. 3. Abdomen becomes distended. Stop enteral feedings. Slide 42 RECORDING AND REPORTING Record and report pH and appearance of aspirate. SPECIAL CONSIDERATION TEACHING: Instruct patient to not pull or alter position of enteral tube. Slide 43 END OF SKILL This is the end of the skill. For SKILL 31-3: Irrigating a Feeding Tube, this will be presented on another power point presentation. Your book has not provided a video for this skill. I would watch the same video that I recommended before: Name of video: Nasogastric tube insertion, irrigation, removal http://www.youtube.com/watch?v=vVEYfRmrCvQ