skills module five NG tube insertion
tube feeding and peg care I would like
to remind you that portions of this
presentation are from chapter 45 in the
text and portions are from chapter 47
please be reminded to review all chapter
objectives as well as the terms in blue
oral feeding assistance with oral
feeding when clients need assistance
with eating it is important to maintain
the clients safety independence and
dignity those at risk for it for
problems with oral feeding include
individuals with frequent pneumonia and
unexplained weight loss to assess a
patient for dysphasia and the definition
for dysphagia is difficulty swallowing
you need to look to see if the patient
has is coughing before or after eating
if they have ferengi or pooling or a
change in voice quality after swallowing
the patient populations where you might
see difficulty swallowing or dysphagia
are those who have suffered CVAs or
strokes Parkinson's disease and/or
dementia those at risk for aspiration
include those having decreased level of
levels of alertness decreased gag reflex
or cough reflex and also those who have
difficulty in managing saliva as a nurse
should you assess any of these mentioned
things it is time to advocate for a
referral for the speech therapist again
dysphagia referred to as or refers to
difficulty swallowing this is identified
by speech therapist and several
recommendations can be made first
there's a screening for dysphagia and
during the screening the therapist may
observe a patient at a meal to observe
for changes in voice quality posture and
head control, percent
of meal consumed drooling or leakage of
liquids or solids
coughing during or after the meal and
choking some recommendations that are
made after the dysphagia screening
could be to elevate the head of the bed
30 minutes prior to eating keeping the
patient upright meaning at a 90 degree
angle for at least 30 minutes after
eating head to chin down or the chin
tuck position to prevent aspiration when
swallowing if there's weakness in the
oral pharyngeal sight you want to place
food on it on the stronger side to chew
do not use straws more frequent chewing
and also taking smaller bites you would
recommend that the patient empty their
mouth completely before eating moreover
for as or before nursing assistive
personnel offer more food and also to
remove food immediately if there are
signs or symptoms that the patient is
choking also with the dysphagia the
patient may be or client may require
verbal coaching for example telling the
client or patient to open their mouth
ask the ask them if they feel the food
in the mouth chewing and tasting the
food you may also have the client or
patient raise their tongue to the roof
of the mouth to think about swallowing
give them instructions to close your
mouth then swallow and then swallow a
second time and also teaching them to
cough to clear their airway again at any
time when you suspect dysphagia or the
patient is having difficulty swallowing
you want to observe for choking gagging
and drooling of food for safety you may
want to have a suction device nearby you
want to also learn to provide rest
periods during the meal to avoid rushed
or forced feeding additionally with
patients that have this dysphagia they may
have to use a thickener there are four
types of liquor
liquid thickener a thin liquid or low
viscosity b. nectar light liquid which
is medium viscosity c. honey like
liquid and then spoon thick liquid such
as putting viscosity you want to always
feed slowly and allow the client to
empty their mouth completely between
feedings and keep in mind that they may
require verbal coaching for each step in
the process so how are diets progressed
clients with acute and chronic
conditions effect affecting the immune
system may also affect nutritional
status these patients may require
special diets to decrease exposure to
microorganisms patients who have had
prolonged illnesses procedures and are
NPO or nothing by mouth for a period of
time may need to have their diet
progressed or advanced take a look at
the slide and you will see the diet
progression NPO means absolutely nothing
by mouth clear liquid diets include
anything that is clear and liquid at
room temperature that could be broth
ginger ale coffee or tea for the full
liquid diet that is anything that is
liquid at room temperature
ice creams custards and cooked cereal
pureed examples are pureed meats and
scrambled eggs
mechanically softened diet includes the
consistency of cottage cheese rice
cooked fruits and vegetables and bananas
then you have the low or soft residue
diet this is these are foods that are
easily digested such as pastas canned
and cooked fruits and vegetables and
desserts without nuts or coconuts you
have the high residue or high fiber diet
which includes fresh uncooked fruits
steamed veggies bran oat meal and dried
another diet is the low-sodium this is
no added salt and it's often called
called the severe sodium restriction
which is less than 500 milligrams this
is going to require that you teach your
patient to read food labels the low
sodium diet also is often required for a
patient who is hypertensive or who has
kidney disease you have the low
cholesterol diet this is a 300 milligram
or less per day of cholesterol some
examples of foods on a low cholesterol
diet include oatmeal fish where you get
the omega-3 fatty acids walnuts and
olives and olive oil all of these help
to reduce cholesterol the diabetic diet
a recommended calorie count of 1,800
calories with a balance of carbohydrates
fats and proteins the gluten-free this
eliminates all wheat
oats rye barley and their derivatives
and then lastly the regular diet which
has no restrictions at all enteral tube
feeding this is where nutrients are
given directly into the GI tract this is
used to meet the nutritional needs of
patients have a functioning GI tract
there are three ways to receive enteral
tube feedings the nasal gastric tube
that is the tube that goes from the nose
to the to the stomach the jejunal tube
or just the gastric or PEG tube gastric
tubes are used to provide nutrition
But and the patient has a low risk
for gastric reflux the gastric tubes are
often inserted percutaneously or
endoscopicly the PEG tube is the percutaneous enteral g-tube it is passed into the
patient's stomach through the abdominal
wall most commonly to provide a means of
feeding when oral intake is not adequate
the jejunal all tube the jejunal tube is
extended into the small intestine
by passing a jejunal extension tube or a
peg J tube through the PEG tube and into
the jejunum peg is the preferred method
if the patient is at high risk for
gastric reflux there are several
different formulas that are utilized in
internal tube feedings they include the
Polimetric modular elemental formulas and specialty
formulas the poly metric tube feedings
are milk based blenderize foods prepared
by staff members at a facility or
in-home their commercially prepared as
some examples of polymeric tube formulas
include ensure or osmo lite in order to
receive these the patient or clients GI
tract must be able to absorb whole
nutrients the modular formula these are
singular macronutrient formulas they
include proteins lipids and polymers and
they are not nutritionally complete
these are added to other foods to meet
the client's nutritional needs
elemental formulas these contain
predigested nutrients that are easily
that are easier for partially
dysfunctional GI tracts to absorb the
elemental formula and then lastly the
specialty formulas they meet specific
nutritional needs for particular
for example pulmonary disease liver
disease and HIV with all tube
feedings you want to start at full
strength but at a low rate and we will
discuss this in the lab the hourly rate
is increased every 8 to 12 hours per
there's no signs of intolerance that
appear you want to monitor patients on
enteral tube feedings for aspiration
there's also tube feedings that are given
as bolus or intermittent tube feedings
where the patient receives feedings at
different intervals throughout the day
as well as the continuous tube feeding
where the patient is hooked to a feeding
pump and they receive feedings at a
certain rate over 24 hours per day
if you take a look in your text you will
see information on feedings on page 10
76 and we will review in class
some complications of enteral tube
feedings include aspiration diarrhea
constipation tube occlusion tube
displacement delayed gastric emptying and
serum electrolyte imbalances please
refer to table 45-7 in your text on
enteral tube feeding complications we
will next review the skill of inserting
in a nasal enteric tube for enteral
feeding please view the yellow pages in
your text beginning on page 1085 keep in
mind that insertion of a tube will make
the client gag you will need to assess
bowel sounds
prior to placement the absence of bowel
sounds may indicate GI problems thus it
is contraindicated to feed the patient
you will also need to test gastric pH
you want to assess bowel sounds by
listening in all four quadrants making
sure that the head of the bed is at
least 30 to 45 degrees to prevent
aspiration you will also check placement
of the tube feeding tube after placement
and before starting every feeding this
verified by x-ray or KUB KUB stands for
kidney ureters and bladder a specific
x-ray test gastric intestinal aspiration
for pH is most accurate for placement
after x-ray normal pH of gastric
contents is 1.0 to 4.0 keeping in mind
that pH is from 0 to 14 anything 7 less
than 7 is acidic greater than 7 is
alkalinic the x-ray is going to be your
most reliable method for confirming
placement of your tube if the patient or
client complaints of cramping when
they're receiving feedings the first
thing you need to do is decrease the
rate or assess prior to feeding that the
fluids are at least room temperature and
not cold as this will cause gastric
cramping another way to check
for placement of the tube is resume
checking for residual of it and we will
practice this in the lab you will check
placement of your enteral tubes via
policy and procedure of the facility in
which you are employed when you aspirate
stomach contents you do not continue to
feed if you have residual that exceeds
500 milliliters again you do not
continue feeding if gastric residual
volume exceeds 500 milliliters also when
you check gastric residual all of the
food or the feeding that you pull out
must be returned this helps the client
to remain in homeostasis or keep the
fluid and electrolyte balance even tube
feedings via the infusion pump this is
the way to provide continuous tube
feedings to your client or patient
continuous tube feedings are tube
feedings that are always on a pump you
want to consult the doctors order for
their actual rate however it is usually
between 40 and 60 milliliters per hour
it is good to maintain a constant rate
and the tubing on the pumps is changed
every 24 hours never discontinue a tube
feeding suddenly as this may cause
hypoglycemic reactions you want to keep
in mind to provide mouth care to your
client at least every two hours if they
are on continuous tube feedings
parenteral nutrition
this is TPN total parenteral nutrition
complications of total parenteral
nutrition include infection of the site
blood clots a fatty liver and often
liver disease you want to administer
this to clients who are unable to digest
or absorb enteral nutrition this is
provided intravenously through a central
line often times a PICC you want to
monitor the site used at a dedicated
port for TPN the central line goes
into the subclavian or the vena cava
vein this placement is confirmed always
by radiology prior to using the PICC
these patients are at risk for an air
embolism you want to prevent air
embolism by placing your patient on the
left side and having them perform the
valsalva maneuver which is bearing down
during the PICC line insertion you want
to prevent occlusion of the PICC by
flushing with saline or heparin per
facility policy with the TPN TPN may
also be known as a lipid emulsion or a
fat emulsion these generally run over 24
hours and contain kilocalories and help
to prevent fatty acid deficiencies again
tubing and TPN should be changed every
24 hours
TPN may also increase blood glucose
levels so blood glucose must be
monitored at least every six hours TPN
and is administered at a constant rate
NG Tube chapter 47 for bowel elimination
NG tube or nasogastric intubation for
decompression this is the removal of
secretions and gaseous substances from
the GI tract or a relief of abdominal
distension the purpose of a nasal
gastric tube can be for enteral
feedings which is to install or place
liquid nutrition inside the NG tube can
also be used for gastric lavage this can
cause irritation of the stomach in cases
of active bleeding poisoning and gastric
violation and also the NG tube can be
used and nasal gastric intubation can be
used as a gastric method of lavage
gavage is the introduction of nutritive
material into the stomach by means of a
tube there are couple tubing types the
Salem sump are the two Lumina tube which
we'll see examples of in the lab it is
connected to a drainage bag or two
intermittent suction the Salem sump tube
is connected to a drainage bag or
intermittent suction this too is
utilized for decompression lavage or
gavage Salem sump used for
decompression lavage or gavage one of
the lumina removes gastric contents and
it is attached to suction and the second
lumina is an air vent which is the blue
pigtail on the tube this provides free
continuous drainage of secretions never
clamp off the air vent if the tube is
connected to suction never clamp off the
air vent if the tube is connected
to suction connected to suction or use
it for irrigation
it is only for draining never clamp off
the vent if the tube is connected to suction
connect or use it for
irrigation this too is only used for
drainage the air vent tube is only used
for drainage the Levine tube or the
single lumen tube is connected to a
drainage bag or for intermittent suction
this can also be used for decompression
lavage or gavage again we will see
examples of each in the lab and we'll
practice insertion of the tube as well
as removal of the tube if you will look
in the skills section of chapter 47
there will be the step-by-step process
of inserting and maintaining a
nasogastric tube for gastric
decompression these will also be
practiced in the lab keep in mind this
does not require a sterile technique
nasal gastric tube insertion does not
require sterile technique before
beginning you want to always assess
vital signs insertion and maintenance
takes place in the high fowlers position
the best way to confirm placement is
however aspiration of gastric contents
in checking pH are other means of
confirming placement you want to measure
drainage and record it as output you
measure the drainage for decompression
nasogastric tubes and record it as
output you also want to remember to
provide oral and nasal hygiene and care
at least every two hours some
complications for the nasal gastric tube
include distended abdomen
dry mucous membranes skin breakdown
around the nares
and also pulmonary aspiration signs and
symptoms of pulmonary aspiration include
fever shortness of breath and pulmonary
again we will practice NG tube insertion
and removal as well as care in the lab
this concludes module 5 NG Tube if you
have any questions please notify your

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