Digestive and Gastrointestinal Treatment Modalities 2

Digestive and Gastrointestinal
Treatment Modalities
Gastrointestinal
Intubation
Gastrointestinal Intubation
Insertion of a flexible tube into the stomach, or beyond the

pylorus into the duodenum (the first section of the small
intestine) or the jejunum (the second section of the small
intestine)
Inserted through the mouth, the nose, or the abdominal

wall.
The tubes are of various diameters (French [Fr] size) and

lengths, depending on their intended use
✓ Decompress the stomach and remove gas and fluid

✓ Lavage (flush with water or other fluids) the stomach and
remove ingested toxins or other harmful materials
✓ Diagnose GI disorders
✓ Administer tube feedings, fluids, and medications
✓ Compress a bleeding site
✓ Aspirate GI contents for analysis
Gastric tubes for decompression, drainage, aspiration, and lavage

Gastric tubes for decompression, drainage, aspiration, and lavage
NURSING MANAGEMENT
✓ Explain the purpose of the tube to the patient prior to

insertion
✓ Review the general activities related to inserting
✓ Procedure may cause gagging until the tube has passed
beyond the throat.
✓ Periodically, the gastric tube’s placement must be verified
Gastric Tubes for Decompression, Drainage, Aspiration, and Lavage
NURSING MANAGEMENT
✓ Ensure that the suction is set at the prescribed pressure

✓ Drainage should be assessed and noted
✓ Sterile saline or water can be used as irrigants
✓ Ensure that oral and nasal hygiene are maintained
Gastric and Enteric Tubes for Administration of Tube Feedings,

Fluids, and Medications
Smaller bore (generally 5 to 12 Fr) than the tubes made for
gastric decompression and drainage, which lessens patient
discomfort and nasal irritation
Gastric or enteric feeding tubes - for patients who have the

ability to receive and process nutrition, fluids, and medications
adequately by the gastric route
Nasoenteric tube or Oroenteric tube – gastroparesis, severe

gastroesophageal reflux disease, impaired glottic closure, or
undergone partial or total gastrectomy

Nasoduodenal tubes - enteric tubes placed in the duodenum
via the nares
Nasojejunal tubes - placed in the jejunum (the portion of the
small intestine distal to the duodenum) via the nares

CONTRAINDICATIONS
✓ Basilar skull fractures

✓ Maxillofacial surgery (including transsphenoidal approaches)
✓ Facial trauma
✓ Uncontrolled coagulation abnormalities

CLEARING TUBE OBSTRUCTION
✓ Warm water irrigation

✓ Milking the tube
✓ Infusing digestive enzymes
✓ Mechanical declogging devices

MONITORING THE PATIENT AND MAINTAINING TUBE FUNCTION
✓ Keep an accurate record of all fluid intake, feedings, and

irrigation volumes
✓ Irrigate with water after every feeding and medication delivery
and every 4 to 6 hours during continuous feedings
✓ Records the amount, color, and type of drainage
✓ Each lumen is labeled according to its intended use for
drainage, medication delivery, or feeding for double or triple
lumen tubes

PROVIDING ORAL AND NASAL HYGIENE
✓ Nose is inspected daily for skin irritation

✓ Nasal tape is changed every 3 days and PRN
✓ Steam or cool vapor inhalations
✓ Throat lozenges, an ice collar, chewing gum, or sucking on hard
candies (if permitted)
✓ Limiting talking to relieve patient discomfort.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS
Common Complications:
✓ Inadvertent misconnections and administrations

✓ Fluid volume deficit
✓ Pulmonary complications
✓ Tube-related irritations

Be vigilant for symptoms of fluid volume such as:
✓ Dry skin and mucous membranes

✓ Decreased urinary output
✓ Lethargy
✓ Lightheadedness
✓ Hypotension
✓ Increased heart rate

Maintain an accurate record of intake and output (I&O)
Include intake from tube feeding and flushes, oral liquids, and
intravenous (iv) fluids
Output of urine, emesis, gastric drainage, diarrhea, ostomies,

fistulas, and drainage tubes should also be measured
Assesses 24-hour fluid balance and report negative fluid balance


Fowler position, and the patient’s head should be elevated at

least 30 to 45 degrees to reduce the risk of reflux and pulmonary
aspiration.
Maintain at least 1 hour after completion of an intermittent tube

feeding
A reverse Trendelenburg when it is not possible or advisable to

elevate the head of the patient’s bed.

Signs and symptoms of pulmonary complications:
✓ Coughing during the administration of foods or medications

✓ Difficulty clearing the airway
✓ Tachypnea
✓ Fever

✓ Regular auscultation of lung sounds

✓ Monitoring of vital signs and laboratory values.
✓ Confirms the proper placement of the tube with a variety of
methods
✓ Radiographic confirmation
CONDITIONS THAT MAY REQUIRE ENTERAL THERAPY

ADMINISTERING TUBE FEEDINGS
ADVANTAGES OVER PARENTERAL NUTRITION (PN):
✓ Lower in cost
✓ Safer
✓ Usually well tolerated by the patient
✓ Easier to use in extended-care facilities and in the patient’s
home

Feeding method chosen depends on the location of the tube in

the GI tract, patient tolerance, convenience, and cost
Feeding method chosen depends on the location of the tube in

the GI tract, patient tolerance, convenience, and cost

Bolus feedings typically are divided into 3 to 4 feedings
Given into the stomach through a large syringe with a plunger or

by gravity
Can be delivered as quickly as the patient can tolerate them but

are initiated slowly

Flow rate is often determined by the patient’s reaction.
If the patient feels full, it may be desirable to slow the delivery

time or give smaller volumes more frequently


The intermittent gravity drip feeding method requires

administering feedings over 30 minutes or longer at designated
intervals by a reservoir enteral bag and tubing, with
the flow rate regulated by a roller clamp or automated pump.

Slow drip feedings may reduce aspiration rates, distention,

nausea, vomiting, and diarrhea in patients with poor gastric
emptying or who are receiving hypertonic feeding solutions, as
well as patients with severe reflux or altered mental status


MAINTAINING FEEDING EQUIPMENT
To ensure patency and to decrease the chance of bacterial

growth, sludge build-up, or occlusion of the tube, at least 30 mL
of water is given in each of the following instances:

✓ Before and after intermittent tube feeding and medication

administration (with at least 5 mL of water in between each
individual medication)
✓ After checking for gastric residuals and gastric pH


✓ Every 4 hours with continuous feedings
✓ When the tube feeding is discontinued or interrupted for any

reason
✓ When the tube is not being used, where a minimum of once

daily
✓ flushing is recommended

PROVIDING MEDICATIONS BY TUBE
Bolus method is used for administration that is compatible with

the medication’s preparation.
Flushed with 30 mL of water before and after medication

Administration
Small-bore feeding - 30-mL or larger syringe is used because the

pressure generated by smaller syringes could rupture the tube.

MAINTAINING DELIVERY SYSTEMS
Open System - Liquid or a powder to be mixed with water that is

either poured into a feeding container or given by a large syringe
Feeding container and the tubing used with the open system
should be changed every 24 hours
Formula hang time in the bag at room temperature should never

exceed what the formula manufacturer recommends (4-8 hours)

MAINTAINING DELIVERY SYSTEMS
Closed delivery systems-prefilled, sterile container of about

1 L of formula that is spiked with enteral tubing
Hang time of 24 to 48 hours at room temperature.
Used with a pump to control formula rate in order to avoid

dispensing a large formula volume in a short period of time

MAINTAINING NORMAL BOWEL ELIMINATION PATTERN

PREVENTING DUMPING SYNDROME
✓ Slow the formula instillation rate to provide time for

carbohydrates and electrolytes to be diluted.
✓ Administer feedings at room temperature, because

temperature extremes stimulate peristalsis.

✓ Administer feeding by continuous drip (if tolerated) rather

than by bolus, to prevent sudden distention of the intestine.
✓ Advise the patient to remain in semi-Fowler position for 1 hour

after the feeding;

✓ Instill the minimal amount of water needed to flush the tubing

before and after a feeding, because fluid given with a feeding
increases intestinal transit time.

MAINTAINING ADEQUATE HYDRATION
Many cases the patient cannot communicate the need for water.
Water flushes are given every 4 hours and after feedings to

prevent hypertonic dehydration.
The feeding may be initially given as a continuous drip in order to

help the patient develop tolerance

MAINTAINING ADEQUATE HYDRATION
Key nursing interventions:
✓ Observing for signs of dehydration (e.g., dry mucous

membranes, thirst, decreased urine output)
✓ Administering water routinely;
✓ Monitoring I&O, residual volume, and fluid balance.

PROMOTING COPING ABILITY
✓ Support and encourage the patient to accept physical changes

✓ Convey hope that daily progressive improvement is possible
✓ Encourage self-care within the parameters
✓ Reinforces an optimistic approach by identifying indicators of
progress (daily weight trends, electrolyte balance, absence of
nausea and diarrhea, improvement in plasma proteins).

PROMOTING COPING ABILITY
For tube feeding at home, the patient should:
✓ Be medically stable and successfully tolerating at least 60% to

70% of the feeding regimen
✓ Be capable of self-care or have a caregiver willing to assume
the responsibility
✓ Have access to supplies and interest in learning how to
administer tube feedings at home
Gastrostomy and
Jejunostomy
Gastrostomy and Jejunostomy
GASTROSTOMY-an opening is created into the stomach either

for the purpose of:
✓ Administering nutrition, fluids, and medications via a feeding

tube
✓ Gastric decompression in patients with gastroparesis,

gastroesophageal reflux disease, or intestinal obstruction
Preferred over a nasally inserted tube to deliver enteral

nutrition support longer than 4 weeks
Preferred for comatose because the gastroesophageal

sphincter remains intact, making regurgitation and aspiration
less likely.
Catheter fixation. Balloon fixation.

JEJUNOSTOMY - surgically placed opening into the jejunum

for the purpose of administering nutrition, fluids, and
medications.
Indicated when the gastric route is not accessible, or to

decrease aspiration risk when the stomach is not functioning
adequately
NURSING PROCESS
ASSESSMENT
✓ Determine the patient’s ability to understand and cooperate

with the procedure
✓ Assess the ability of both patient and family to adjust to a
change in body image and to participate in self-care
✓ Discuss medical and ethical issues with the patient, the
caregivers, and the primary provider
NURSING PROCESS
NURSING DIAGNOSES
❖ Imbalanced nutrition: less than body requirements

❖ Risk for infection related to presence of wound and tube
❖ Risk for impaired skin integrity at tube insertion site
❖ Disturbed body image related to presence of tube
NURSING PROCESS
NURSING DIAGNOSES
COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS

❖ Potential complications may include the following:
❖ Wound infection, cellulitis, and leakage
❖ GI bleeding
❖ Premature dislodgement of the tube
NURSING PROCESS
PLANNING AND GOALS
The Major Goals:

❖ Achieving nutritional requirements
❖ Preventing infection
❖ Maintaining skin integrity
❖ Adjusting to changes in body image
❖ Preventing complications.
NURSING PROCESS
NURSING INTERVENTIONS
❖ Meeting nutritional needs

❖ Preventing infection and providing skin care
❖ Enhancing body image
❖ Monitoring and managing potential complications
❖ Promoting home, community-based, and transitional care
NURSING PROCESS
EVALUATION
1. Achieves nutrition goals
a. Attains weight goal
b. Tolerates tube feeding prescription without nausea, emesis,
cramping, abdominal pain, or feelings of early satiety
c. Has acceptable bowel movements without constipation or
largevolume liquid stools
d. Has normal plasma protein, glucose, vitamin, and mineral
levels
e. Has normal electrolyte values
NURSING PROCESS
EVALUATION
2. Is free of infection at enteral access site

a. Is afebrile
b. Has no induration, redness, pain, or purulent drainage
c. Has no scattered papules indicative of a yeast infection
NURSING PROCESS
EVALUATION
3. Has dry, intact skin surrounding enteral access site

a. No evidence of excessive drainage or bleeding
b. No skin breakdown or hypertrophic tissue growth
4. Adjusts to change in body image

a. Is able to discuss expected changes
b. Verbalizes concerns
NURSING PROCESS
EVALUATION
5. Demonstrates skill in tube care

a. Handles equipment competently
b. Demonstrates how to maintain tube patency
c. Keeps an accurate record of I&O
d. Demonstrates how to gently wash tube site daily and keep
clean and dry
NURSING PROCESS
EVALUATION
6. Avoids other complications

a. Exhibits adequate wound healing
b. Tube remains intact and is routinely replaced for the duration
of therapy
PARENTERAL
NUTRITION
PARENTERAL NUTRITION
Method of providing nutrients to the body by an IV route
Nutrients are a complex admixture containing proteins,

carbohydrates, fats, electrolytes, vitamins, trace minerals, and
sterile water in a single container
THE GOALS OF PN:
➢ Improve nutritional status

➢ Establish a positive nitrogen balance
➢ Maintain muscle mass
➢ Promote weight maintenance or gain
➢ Enhance the healing process
INDICATIONS FOR PARENTERAL NUTRITION

INITIATING THERAPY
PN solutions are initiated slowly and advanced gradually
Laboratory test results and response to PN therapy are

monitored
Standing orders are initiated for:

✓ Weighing the patient
✓ Monitoring I&O and blood glucose
✓ Complete blood count, platelet count, and chemistry panel,
including serum carbon dioxide, magnesium, phosphorus,
and triglycerides.
ADMINISTRATION METHODS
PERIPHERAL METHOD
✓ Given through a peripheral vein

✓ Solution is less hypertonic
✓ Not nutritionally complete because of their low dextrose
content
✓ Lipids are given simultaneously to buffer the PPN and to
protect the peripheral vein from irritation
✓ Usual length of therapy using PPN is 5 to 7 days.
CENTRAL METHOD
ntral parenteral nutrition (CPN) solutions
Given into the vascular system through a catheter
inserted into a high-flow, large blood vessel (e.g., ideally at the
superior vena cava/right atriocaval junction)
Concentrated solutions are then very rapidly diluted to isotonic

levels by the blood in this vessel.
CENTRAL METHOD
Types of central venous access device (CVADs):

✓ Percutaneous (or nontunneled)
✓ Peripherally inserted central catheters (PICS)
✓ Surgically placed (or tunneled) catheters
✓ Implanted vascular access ports.
CENTRAL METHOD
Types of central venous access device (CVADs):

✓ Percutaneous (or nontunneled)
✓ Peripherally inserted central catheters (PICS)
✓ Surgically placed (or tunneled) catheters
✓ Implanted vascular access ports.
CENTRAL METHOD
Percutaneous (Nontunneled) Central Catheters
✓ Used for short-term (less than 6 weeks)

✓ Subclavian vein is the most common vessel accessed
✓ Subclavian access site should be avoided in patients with
advanced kidney disease
✓ Second most common access sites include the basilic,
brachial, or cephalic veins in the arm followed by the
jugular vein
✓ Femoral vein should be avoided for risk for infection
CENTRAL METHOD
PCC
Subclavian triple-lumen catheter

used for parenteral nutrition and
other adjunctive therapy
CENTRAL METHOD
PERIPHERALLY INSERTED CENTRAL CATHETERS
Used for intermediate-term (several days to months) IV

therapy in the hospital, long-term care, or home setting
Basilic, brachial, or cephalic vein is accessed above the

antecubital space, and the catheter is threaded to the superior
vena cava/right atriocaval junction
Taking of blood pressure and blood specimens from the

extremity with the PICC is avoided.
CENTRAL METHOD
PERIPHERALLY INSERTED CENTRAL CATHETERS
CENTRAL METHOD
SURGICALLY PLACED (TUNNELED) CENTRAL CATHETERS
✓ Surgically placed central catheters are for long-term use and

Catheters are cuffed and can have single or double lumens
✓ Examples are the Power line (Power injectable), Hickman,
Groshong, and Permacath.
✓ Inserted surgically then threaded (or tunneled) under the
skin to the subclavian vein and advanced into the superior
vena cava into the superior vena cava.
CENTRAL METHOD
SURGICALLY PLACED (TUNNELED) CENTRAL CATHETERS
CENTRAL METHOD
IMPLANTED VASCULAR ACCESS PORTS
✓ For long-term IV therapy

✓ Examples include the Power injectable Port-A-Cath,
Mediport, Hickman Port, and P.A.S. Port
✓ Catheter is attached to a small chamber that is placed in a
subcutaneous pocket
✓ Requires minimal care and allows the patient complete
freedom of activity.
✓ Implanted ports are more expensive
CENTRAL METHOD
IMPLANTED VASCULAR ACCESS PORTS
DISCONTINUING PARENTERAL NUTRITION
Discontinued gradually to allow the patient to adjust to

decreased levels of glucose.
Isotonic dextrose can be given at the same rate the PN solution

was infusing for 1 to 2 hours to prevent rebound hypoglycemia
if to be discontinued immediately
Symptoms of rebound hypoglycemia include:

✓ Weakness
✓ Faintness
✓ Sweating
✓ Shakiness
✓ Feeling cold
✓ Confusion
✓ Increased heart rate
✓ Once completed the percutaneous central venous catheter

or PICC is removed
✓ Pressure is held until hemostasis is achieved
✓ Occlusive dressing is applied to the exit site
✓ Surgically placed central catheters and implanted vascular
access ports are removed only by the primary provider
NURSING PROCESS
ASSESSMENT
Indicators include significant weight loss (10% or more of usual

weight), a decrease in oral food intake for more than 1 week,
muscle wasting, decreased tissue healing, abnormal urea
nitrogen excretion, and persistent vomiting and diarrhea
The nurse carefully monitors the patient’s hydration status,

electrolyte levels, and calorie intake.
NURSING PROCESS
NURSING DIAGNOSES
✓ Imbalanced nutrition: less than body requirements related to

✓ inadequate oral intake of nutrients
✓ Risk for infection related to contamination of the central
catheter site or infusion line
✓ Risk for imbalanced fluid volume related to altered infusion
rate
✓ Risk for activity intolerance related to restrictions because of
the presence of IV access device
NURSING PROCESS
NURSING PROCESS
NURSING PROCESS
PLANNING AND GOALS
✓ Include optimal level of nutrition

✓ Absence of infection
✓ Adequate fluid volume
✓ Optimal level of activity (within individual limitations)
knowledge of and skill in selfcare
✓ Absence of complications.
NURSING PROCESS
NURSING INTERVENTIONS
✓ Maintaining optimal nutrition

✓ Preventing infection
✓ Maintaining fluid balance
✓ Encouraging activity
✓ Promoting home, community-based, and transitional care
NURSING PROCESS
EVALUATION
Expected patient outcomes may include the following:
1. Attains or maintains nutritional balance

2. Is free of catheter-related infection
a. Is afebrile
b. Has no purulent drainage from the catheter insertion site
NURSING PROCESS
EVALUATION
3. Is hydrated, as evidenced by good skin turgor

4. Achieves an optimal level of activity, within limitations
5. Demonstrates skill in managing PN regimen
NURSING PROCESS
EVALUATION
6. Prevents complications
a. Maintains proper catheter and equipment function
b. Maintains metabolic balance within normal limits

Digestive and Gastrointestinal Treatment Modalities 2

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Digestive and Gastrointestinal Treatment Modalities 2

Uploaded by

Copyright:

Available Formats

Digestive and Gastrointestinal

Insertion of a flexible tube into the stomach, or beyond the

Inserted through the mouth, the nose, or the abdominal

The tubes are of various diameters (French [Fr] size) and

✓ Decompress the stomach and remove gas and fluid

Gastric tubes for decompression, drainage, aspiration, and lavage

Gastric tubes for decompression, drainage, aspiration, and lavage

✓ Explain the purpose of the tube to the patient prior to

Gastric Tubes for Decompression, Drainage, Aspiration, and Lavage

✓ Ensure that the suction is set at the prescribed pressure

Gastric and Enteric Tubes for Administration of Tube Feedings,

Gastric or enteric feeding tubes - for patients who have the

Nasoenteric tube or Oroenteric tube – gastroparesis, severe

Gastric and Enteric Tubes for Administration of Tube Feedings,

Gastric and Enteric Tubes for Administration of Tube Feedings,

✓ Basilar skull fractures

Gastric and Enteric Tubes for Administration of Tube Feedings,

✓ Warm water irrigation

Gastric and Enteric Tubes for Administration of Tube Feedings,

✓ Keep an accurate record of all fluid intake, feedings, and

Gastric and Enteric Tubes for Administration of Tube Feedings,

✓ Nose is inspected daily for skin irritation

Gastric and Enteric Tubes for Administration of Tube Feedings,

✓ Inadvertent misconnections and administrations

Gastric and Enteric Tubes for Administration of Tube Feedings,

Be vigilant for symptoms of fluid volume such as:

✓ Dry skin and mucous membranes

Gastric and Enteric Tubes for Administration of Tube Feedings,

Maintain an accurate record of intake and output (I&O)

Output of urine, emesis, gastric drainage, diarrhea, ostomies,

Assesses 24-hour fluid balance and report negative fluid balance

Gastric and Enteric Tubes for Administration of Tube Feedings,

Fowler position, and the patient’s head should be elevated at

Maintain at least 1 hour after completion of an intermittent tube

A reverse Trendelenburg when it is not possible or advisable to

Gastric and Enteric Tubes for Administration of Tube Feedings,

Signs and symptoms of pulmonary complications:

✓ Coughing during the administration of foods or medications

Gastric and Enteric Tubes for Administration of Tube Feedings,

✓ Regular auscultation of lung sounds

Gastric and Enteric Tubes for Administration of Tube Feedings,

ADVANTAGES OVER PARENTERAL NUTRITION (PN):

Gastric and Enteric Tubes for Administration of Tube Feedings,

Feeding method chosen depends on the location of the tube in

Feeding method chosen depends on the location of the tube in

Gastric and Enteric Tubes for Administration of Tube Feedings,

Bolus feedings typically are divided into 3 to 4 feedings

Given into the stomach through a large syringe with a plunger or

Can be delivered as quickly as the patient can tolerate them but

Gastric and Enteric Tubes for Administration of Tube Feedings,

Flow rate is often determined by the patient’s reaction.

If the patient feels full, it may be desirable to slow the delivery

Gastric and Enteric Tubes for Administration of Tube Feedings,

Gastric and Enteric Tubes for Administration of Tube Feedings,

The intermittent gravity drip feeding method requires

Gastric and Enteric Tubes for Administration of Tube Feedings,

Slow drip feedings may reduce aspiration rates, distention,

Gastric and Enteric Tubes for Administration of Tube Feedings,

Gastric and Enteric Tubes for Administration of Tube Feedings,

To ensure patency and to decrease the chance of bacterial

Gastric and Enteric Tubes for Administration of Tube Feedings,

✓ Before and after intermittent tube feeding and medication

✓ After checking for gastric residuals and gastric pH