ATI Chapter 54: Nasogastric Intubation & Enteral Feedings

Nasogastric intubation
insertion of nasogastric NG tube to manage gastrointestinal dysfunction & provide enteral nutrition
-NG tubes, enteral tube feedings can be delivered via jejunal or gastric tubes
-Insertion & maintenance of nasogastric/enteral feeding tubes is nurse’s responsibility

Nasogastric NG tube-
hollow, flexible, cylindrical device inserted through nasopharynx into stomach

-Removal of gases or stomach contents to relieve distention, nausea, or vomiting
-Tube types: Salem sump, Miller-Abbott, Levin

-Route administering nutritional supplements when oral/esophageal passageways cannot be used
Tube types: Duo, Levin, Dobbohoff

-Washing out stomach to treat overdose or ingestion of poison
Tube types: Eweald, Levin, Salem sump

-Applied pressure using internal balloon to prevent hemorrhage
-Tube type- Sengstaken-Blakemore

Procedure: Nursing Actions
-Review prescription & purpose, plan for drainage or suction & understand the need for placement for diagnostic purposes
-Identify client & explain procedure
-Evaluate client’s ability to assist and/or cooperate
-Perform hand hygiene
-Set up equipment:
Nasogastric tube- selected according to indication
Tape- to secure dressing
Water Soluble lubricant
Cup of water & straw
Catheter- tipped syringe, usually 30 to 60 mL
Basin- to prepare for gag induced nausea
pH test strip or meter- to measure gastric secretions for acidity
Stethoscope- to check placement
Disposable towel- to maintain a clean environment
Clamp or plug- to close tubing after insertion
Suction apparatus- if continuous or intermittent suction is needed
Gauze square- to cleanse outside of tubing after insertion
Safety pin and elastic band- to secure tubing & prevent erroneous removal
Position a disposable towel & basin
Provide privacy

*Intraprocedure: Nursing Actions
-Nurse may require assistance with clients who are confused or disoriented
-Assist client to high-Fowler’s position (if possible)
-Assess the nares for best position/route: assess whether or not client has had any nasopharyngeal surgery or septal deviation to determine which naris to use
-Administer topical anesthetic
-Measure tubing- from tip of nose, to top of ear lobe, to tip of the xiphoid, and mark with adhesive tape
-Put gloves on
-Lubricate tip of tubing
-If client is able, have her hold the cup of water with straw in place, and tell her that she will be told when to drink
-Have client hyperextend her head back
-Gradually insert tube
-When resistance is met, apply gentle pressure downward, and proceed beyond curve of nasopharynx
-Have client lean her head forward and begin sipping as insertion continues. Swallowing helps feed the tubing downward toward stomach
-When tubing reaches mark, anchor the tube suing tape or nasogastric claim
-Placement check:
Ask client to talk
Inspect posterior pharynx for coiled tubing
Aspirate gently to collect gastric contents & observe color
Test pH (4 or less is expected)
Confirm placement with an x-ray as prescribed
-Injecting air into tube & when listening over abdomen is not a acceptable practice
-If tube is not in stomach, advance it 5 cm & repeat placement check
-When placement is confirmed, secure tube to nose using tape
-Clamp nasogastric tube or connect it to appropriate suction device
-If client vomits, clear airway & provide comfort prior to continuing
-Salem sump tubing has a blue pigtail for negative air release. Do not insert any substances into blue pigtail, as it will break seal and tubing will leak

Post Procedure: Nursing Actions
The insertion & maintenance of nasogastric tube is nursing responsibility; but measuring output, providing comfort, & giving oral care can be delegated

-Inform client of order & process, emphasizing that removal is less stressful than placement
-Perform hand hygiene & don gloves
-Remove safety pin from gown, & remove tape-anchoring tube to nose
-Disconnect tubing from suction & claim it
-Provide facial tissues for client
-Instruct client to take & hold deep breath
-Remove tubing with steady continuous pull while client is hold her breath
-Measure & record any drainage
-Clean nares & provide oral care
-Ensure client is confortable
-Dispose of equipment
-Document all relevant information including:
Tubing removal & condition of tube
Volume & description of drainage
Abdominal assessment, including inspection, auscultation, palpation, & percussion
-Last & next bowel movement & urine output

Excoriation (tear or strip) of nares & stomach
-Apply lubricant to nares as needed
-Assess color of nasogastric tube drainage. Report dark “coffee-ground” or blood-streaked drainage to provider immediately
-Rinse client’s mouth with water for dryness
-Throat lozenges may be helpful
-Provide oral hygiene frequently
Occlusion (Obstruction) of NG tube leading to distention
-Irrigate tube per facility protocol to unclog blockages. Tap water may be used with enteral feedings. Have client change position in case tube is against stomach wall

Enteral feedings
is a method of providing nutrients to clients who cannot consume foods orally; Enteral Formulas:

1.0 to 2.0 kcal/mL; milk-based, blenderized foods

Whole nutrient
formulas prepared by hospital dietary staff or commercially prepared; nutritionally complete
-Only used if client’s GI can absorb whole nutrients

Modular formulas
3.8 to 4.0 kcal/mL predigested nutrients
-Not nutritionally complete; provide a single macronutrient
-Easier for partially dysfunctional GI tract to absorb

Specialty formulas
-Not nutritionally complete
-Primarily for clients who have hepatic failure, respiratory disease, or HIV infection

Enteral Access Tubes
Nasogastric or Nasointestinal
Therapy duration shorter than 4 weeks; Inserted via nose

Gastrostomy or jejunostomy
therapy duration longer than 4 weeks; Inserted surgically

Percutaneous endoscopic gastrostomy PEG or jejunostomy PEJ
therapy duration longer than 4 weeks; Inserted endoscopically

Enteral Access Tubes
* Surgical & endoscopic insertion presents an increased risk or injury & infection; therefore, they are only indicated for long-term use
*Gastroparesis, esophageal reflux, or history of aspiration pneumonia generally requires intestinal placement*

Nursing Actions: Preparation of Client
*Nursing Actions: Preparation of Client
-Review client’s prescription: PCP usually determines the type of tube feeding formula in consultation with dietary staff
-Set up equipment
-Feeding bag
-30 to 60 mL syringe (compatible with tubing)
-pH indicator strip
-Infusion pumps (if not a gravity drip_
-Appropriate enteral formula
-Irrigation solution or tap water, according to facility policy
-Supplies for blood glucose (if protocol or orders indication)

Ongoing Care
Prepare formula, tubing, & infusion device
-Check expiration dates & note content of formula
-Assure formula is at room temperature
-Setup feeding system via gravity or pump
-Mix or shake formula, fill container, prime tubing, and clamp it
Assist client to Fowler’s position or elevate head of bed to minimum of 30
Monitor Tube Placement
-Check gastric contents for pH. Good indication of appropriate placement is obtaining gastric contents with pH between 0 & 4
-Aspirate for residual volume; intestinal residual should be less than 10 mL, & gastric residual less than 100 mL
-Note appearance of aspirate
-Return aspirated contents or follow facility protocol
Flush tubing with 30 to 60 mL of tap H20
Administer formula
Intermittent feeding: have formula & a 60 mL syringe prepared
-Remove plunger from syringe
-Hold tubing above instillation site
-Open stopcock on tubing, and insert barrel of syringe with end up
-Fill syringe with 40 to 50 mL of formula
-If using a feeding bag, fill bag with total amount of formula prescribed for one feeding, and hang it to drain via gravity until empty (about 30 min)
-If using syringe, hold it high enough for formula to empty gradually via gravity
-Continue to refill syringe until amount prescribed for feeding is instilled
-Follow with 60 to 100 mL of tap water (or amount prescribed) to flush tube & prevent clogging

Continuous-drip Feeding
-Connect feeding bag system to feeding tube
-If using a pump, program the instillation rate as prescribed, and set the total volume to instill
-Start pump
-Flush enteral tubing with 30 to 60 mL of irrigant, usually tap water, every 4 to 6 hr, and check tube placement again
-Monitor intake & output & include 24 hr. totals
-Monitor capillary blood glucose every 6 hrs. until max administration rate is reached & maintained for 24 hrs.
-An infusion pump is required for intestinal tube feedings
-Follow manufacturer’s recommendations for formula hang time. Unused formula should be refrigerated & discarded after 24 hrs.
-Gastric residual should be checked every 4 to 8 hr. Facility protocol specifies the actions to take based on amount of residual obtained
-Delegation of this skill to assistive personnel is INAPPROPRIATE

*When gastric residuals exceeds 100 mL (10 mL for intestinal placement)
-Withhold feeding
-Notify provider
-Maintain semi-Fowler’s position
-Recheck residual in 1 hr or as prescribed
*Diarrhea 3 times or more in 24-hr period
-Notify provider
-Confer with dietitian
-Provide skin care & protection
*Nausea or Vomiting
-Withhold feeding
-Turn client to side*
-Notify provider
-Aspirate for residual
-Auscultate for bowel sounds
Aspiration of formula
-Withhold feeding
-Turn client to side
-Suction airway
-Provide O2 if indicated
-Monitor client’s vital signs for elevated temperature
-Auscultate breath sounds for increased congestion
-Notify the provider
-Obtain chest x-ray
Skill irritation around tubing site
-Provide skin barrier from any drainage at site
-Monitor tube’s placement

A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following is an appropriate response by the nurse?
A. “Water helps clear the tube so it doesn’t get clogged.”
B. “Flushing helps make sure the tube stays in place.”
C. “This will help you get enough fluids.”
D. “Adding water makes the formula less concentrated.”

A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. Which of the following is the nurse’s highest assessment priority before performing this procedure?
A. Check how long the feeding container has been open.
B. Verify the placement of the NG tube.
C. Confirm that the client does not have diarrhea.
D. Make sure the client is alert and oriented.

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding?
A. Auscultate breath sounds.
B. Stop the feeding.
C. Obtain a chest x-ray.
D. Initiate oxygen therapy.

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following is an appropriate nursing action prior to administering the tube feeding? (Select all that apply.)
A. Auscultate bowel sounds.
B. Assist the client to an upright position.
C. Test the pH of gastric aspirate.
D. Warm the formula to body temperature. E. Discard any residual gastric contents.
A, B, C

A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the
following actions should the nurse perform before beginning the procedure? (Select all that apply.)
A. Review a signal the client can use if feeling any distress.
B. Lay a towel across the client’s chest.
C. Administer oral pain medication.
D. Obtain a Dobhoff tube for insertion.
E. Have a petroleum-based lubricant available.
A, B

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