Chapter 44
Digestive and Gastrointestinal
Treatment Modalities
Purposes of Gastrointestinal Intubation
 Decompress the stomach
 Lavage the stomach
 Diagnose GI disorders
 Administer medications and feeding
 To compress a bleeding site
 To aspirate gastric contents for analysis
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Types of Tubes
 Lavage tubes
o Levin
o Gastric (Salem) Sump
 Enteric tubes
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Gastric Sump Tube
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Question #1
What is a nasogastric tube?
A. Tube inserted through the nose into the beginning of
the small intestine
B. Tube inserted through the nose into the stomach
C. Tube inserted through the nose into the second
portion of the small intestine
D. Tube inserted through the mouth into the stomach
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Answer to Question #1
B. Tube inserted through the nose into the stomach
A nasoduodenal tube is inserted through the nose into
the beginning of the small intestine. A nasogastric tube
is inserted through the nose into the stomach. A
nasojejunal tube is inserted through the nose into the
second portion of the small intestine. An orogastric tube
is inserted through the mouth into the stomach
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Purposes and Advantages of Enteral
Feedings
 Meet nutritional requirements when oral intake is
inadequate or not possible, and the GI tract is
functioning
 Advantages
o Safe and cost effective
o Preserve GI integrity
o Preserve the normal sequence of intestinal and
hepatic metabolism
o Maintain fat metabolism and lipoprotein synthesis
o Maintain normal insulin and glucagon ratios
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Tube Feeding Administration Methods
 Tubes
o Nasogastric or nasoenteral tubes
o Gastrostomy or jejunostomy tubes for long-term
feeding
 Methods
o Intermittent bolus feedings
o Intermittent gravity drip
o Continuous infusion
o Cyclic feeding
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Bolus Gastrostomy Feeding by Gravity
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Question #2
Is the following statement true or false?
Cyclic feedings are administered into the stomach in
large amounts and at designated intervals
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Answer to Question #2
False
Bolus feedings are administered into the stomach in
large amounts and at designated intervals. Cyclic
feedings are periodic feedings given over a short
period of time
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Nursing Care of the Patient With a Nasogastric,
Nasoenteric, Gastrostomy, or Jejunostomy Tube
 Patient education and preparation
 Tube insertion
 Confirming placement
 Clearing tube obstruction
 Monitoring the patient
 Maintaining tube function
 Oral and nasal care
 Monitoring, preventing, and managing complications
 Tube removal
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Measuring for Nasogastric Tube Insertion
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Securing the Nasogastric Tube
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Nasoenteric Feeding by Continuous
Controlled Pump
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Delivery Options for Parenteral Therapy
 Parenteral method: Peripheral
 Central method: central venous access devices (CVAD)
o Percutaneous (nontunneled) catheter
o Peripherally inserted central catheter (PICC)
o Tunneled central catheter (surgically placed)
o Implanted vascular access ports
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Subclavian Triple Lumen
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Question #3
Is the following statement true or false?
The nasogastric tube is secured to the nose with tape
to prevent injury to the nasopharyngeal passages
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Answer to Question #3
True
The nasogastric tube is secured to the nose with tape to
prevent injury to the nasopharyngeal passages
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Nursing Process: The Care of the Patient
Receiving an Enteral Feeding—Assessment
 Tube placement
 Patient’s ability to tolerate formula and amount
 Clinical response
 Signs of dehydration
 Elevated blood glucose level, decreased urinary output,
sudden weight gain, and periorbital or dependent edema
 Infections control practices
 Check gastric residual
 I & O, weekly weights, dietician consult
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Collaborative Problems and Potential
Complications #1
 Diarrhea
 Nausea and vomiting
 Gas, bloating, cramping
 Dumping syndrome
 Aspiration pneumonia
 Tube displacement
 Tube obstruction
 Nasopharyngeal irritation
 Hyperglycemia
 Dehydration and azotemia
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Nursing 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 and
skill in self-care, and prevention of complications
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Maintaining Nutrition Balance and Tube
Function
 Administer feeding at prescribed rate and method and
according to patient tolerance.
 Measure gastric residual volumes (GRV) before intermittent
feedings and every 4 to 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
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Maintaining 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 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
 Avoid cold TF
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Reduce Risk for Aspiration
 Elevate head of bed at least 30 to 45 degrees during and
for at least 1 hour after feedings
 Monitor residual volumes
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Other 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 education
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Question #4
What position should the patient’s head be in when
receiving a tube feeding to prevent aspiration?
A. Flat
B. 10 to 20 degrees of elevation
C. 30 to 45 degrees of elevation
D. 60 to 90 degrees of elevation
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Answer to Question #4
C. 30 to 45 degrees of elevation
The semi-Fowler position is necessary for an NG feeding
with the patient’s head elevated at least 30 to 45
degrees to reduce the risk of aspiration
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Nursing Process: The Care of the Patient With a
Gastrostomy or Jejunostomy —Assessment
 Patient knowledge and ability to learn
 Self-care ability and support
 Skin condition
 Nutrition and fluid status
 Inspection of the tube
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Nursing Process: The Care of the Patient With a
Gastrostomy or Jejunostomy—Diagnoses
 Imbalanced nutrition
 Risk of infection
 Risk for impaired skin integrity
 Disturbed body image
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Collaborative Problems and Potential
Complications #2
 Wound infection, cellulitis, leakage
 GI bleeding
 Premature dislodgment of tube
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Nursing Process: The Care of the Patient With a
Gastrostomy or Jejunostomy—Planning
 Major goals include
o Attaining an optimal level of nutrition
o Preventing infection
o Maintaining skin integrity
o Adjusting to changes in body image
o Preventing complications
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Additional Care
 Meet nutritional needs
 Prevent infection: proper use of dressing; skin care
around the tube; manipulation of the stabilizing disk to
prevent skin breakdown
 Enhance body image
 Monitor for potential complications
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PEG Tube
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PEG Dressing
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Parenteral 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, establish a positive nitrogen balance,
maintain muscle mass, promote weight maintenance or
gain, and enhance the healing process
 May be delivered peripherally or via a central line,
depending on the solution’s hypertonicity
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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 or is unwilling to ingest adequate
nutrients
 The underlying medical condition precludes oral or tube
feeding
 Preoperative and postoperative nutritional needs are
prolonged
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Nursing Process: The Care of the Patient
Receiving Parenteral Nutrition—Assessment
 Assist in identifying patients who are candidates for PN
o Nutrition status; decreased oral intake >1 week
o Weight loss 10% or more of usual wt
o Muscle wasting, decreased tissue healing
o Persistent N&V
 Hydration status
 Electrolytes
 Caloric intake
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Nursing Process: The Care of the Patient
Receiving Parenteral Nutrition—Diagnoses
 Imbalanced nutrition
 Risk for infection
 Risk for imbalanced fluid volume
 Risk for activity intolerance
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Collaborative Problems and Potential
Complications #3
 Pneumothorax, air embolism
 Clotted or displaced catheter
 Sepsis
 Hyperglycemia
 Rebound hypoglycemia
 Fluid overload
 Refer to Table 44-5
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Nursing Process: The Care of the Patient
Receiving Parenteral Nutrition—Planning
 Major goals include:
o Attaining an optimal level of nutrition
o Absence of infection
o Adequate fluid volume
o Optimal level of activity
o Knowledge of self-care
o Absence of complications
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Maintaining Optimal Nutrition
 Daily weight at same time of day
 Accurate I&O
 Caloric count
 Trace elements included in solution
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Prevention 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
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Maintaining 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
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Patient Education
 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
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Question #5
What is total nutrient admixture?
A. Method of supplying nutrients to the body by the
intravenous route
B. An oil in water emulsion of oils, egg phospholipids, and
glycerin
C. A device designed and used for long-term
administration of medications and fluids into central
veins
D. An admixture of lipid emulsions, proteins,
carbohydrates, electrolytes, vitamins, trace minerals,
and water
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Answer to Question #5
D. An admixture of lipid emulsions, proteins,
carbohydrates, electrolytes, vitamins, trace
minerals,
and water
Parenteral nutrition is a method of supplying nutrients
to the body by the intravenous route. Intravenous fat
emulsion is an oil-in-water emulsion of oils, egg
phospholipids, and glycerin. A central venous access
device is designed and used for long-term
administration of medications and fluids into central
veins. Total nutrient admixture is lipid emulsions,
proteins, carbohydrates, electrolytes, vitamins, trace
minerals, and water
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Collaborative Problems and Potential
Complications #4
 Diarrhea
 Nausea and vomiting
 Gas, bloating, cramping
 Dumping syndrome
 Aspiration pneumonia
 Tube displacement
 Tube obstruction
 Nasopharyngeal irritation
 Hyperglycemia
 Dehydration and azotemia
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Nursing Measures for Potential
Complications
 Assess fluid balance
 Review medications
 Assess respiratory status
 Declog tube per protocol
 Monitor blood glucose levels
 Monitor for dehydration
 Dietician consult
 Refer to Chart 44-3
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