Nursing Considerations in the Use of Feeding Tubes … Essay
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¶ … nasogastric tubes and PEG tubes? How does a nurse check placement for each?
A nasogastric tube is used to provide gastric intubation for diagnostic and therapeutic purposes through the nasal passage (Shlamovitz & Kate, 2015). The placement of nasogastric tubes may be an unpleasant experience for patients if they are not anesthetized properly and educated to remain cooperative with the nurse during placement (Shlamovitz & Kate, 2015). A nurse should check placement for a nasogastric tube as illustrated in Figure 1 and described below.
Nasogastric tube insertion steps
Placement is checked by the following steps:
Instruct patient to talk;
Inspect posterior pharynx for coiled tube;
Attach catheter tip syringe to end of tube and aspirate contents -- check color and pH; and,
Order X-ray to check tube placement (Nasogastric tube insertion steps, 2015).
By contrast, percutaneous endoscopic gastrostomy (PEG) tubes (depicted in Figure 2 below) are used for the administration of artificial nutrition, particularly in elderly patients suffering from dementia (Vitale & Hiner, 2009).
Figure 2. PEG tube insertion
An endoscope is used to check proper placement of the PEG tube (PEG tube placement, 2015).
How would a nurse check for gastric residual with a PEG tube? How much gastric residual is considered too much?
Nurses check for gastric residual using refractometrythat provides a Brix value which measures the amount of dissolved materials in a solution; the Brix value is typically higher for enteral nutrition formula than for secretions (Fessler, 2010). Although a wide range of recommendations have been advanced concerning how much gastric residual is regarded as too much, current enteral practice recommendations indicate that nurses should check gastric residual volume every 4 hours over the course of the initial 48 hours of gastric feeding; thereafter, nurses should check gastric residual volume every 6 to 8 hours in those cases where patients are not critically ill (Fessler, 2010). The current American Society for Parenteral and Enteral Nutrition guidelines for nutrition support in patients who are critically ill stipulate that nurses should not stop enteral nutrition for gastric residual values lower than 500 mL except in those cases where other signs of feeding intolerance are evident (Fessler, 2010). According to Fessler, "Gastric residual volumes ranging from 200 to 500 mL should prompt clinicians to implement methods to reduce aspiration risk" (p. 8).
Describe the steps a nurse will use to administer a medication (pill) via a feeding tube.
Medications in pill form require crushing prior to administration to ensure the contents are small enough to pass through the feeding tube without clogging it (Giving medications through a feeding tube, 1999). The steps to administering pill-form medications are as follows:
Position patient on back with head elevated at least 45 degrees.
Wash hands before handling the tubing and medication.
Prepare one medication at a time.
Crush tablets in at least 30cc of water (check the list of which medications may be crushed).
Unclamp the feeding tube.
Uncap the end of the feeding tube or remove the covering.
Check the tube for proper placement to be sure it is safe to give the feeding.
Attach a 60 cc syringe to the end of the feeding tube and pull back on the plunger to verify yellow-green stomach fluid contents; return these contents into the stomach by pushing on the plunger (if fluid is not withdrawn, reposition the patient).
Remove the plunger from the syringe. Put the end of the syringe into the opening of the tube. Raise the syringe above the level of the stomach, but not more than 12 inches above the stomach.
Slowly pour in 20-30ml of warm water, letting it drain in by gravity. If the water flows in easily, then follow with the medicine. If the water does not flow easily, raise or lower the height of the syringe.
Administer one medication at a time.
Flush tube with 20-30ml of water between medications.
Flush tube with 60ml of warm water after the final medication.
If patient is on continuous feedings, please check with hospice nurse to see if it is necessary to hold feedings before or after administration of medications.
Clamp off the tube and remove the syringe or funnel.
Plug or cap the end of the tube.
Wash the syringe and plunger in warm, soapy water and rinse thoroughly. Air dry and store in a clean covered container (Giving medications through a feeding tube, 1999).
What are the complications of administering tube feedings? Describe ways to prevent these complications.
Nasogastric feeding tubes exert pressure against the nostrils and pharynx which can result in ulceration (Hamel & Walter, 2007). In addition, feeding tubes can also cause interference with sinus drainage that can result in blockage and infection (Hamel & Walter, 2007) as well as aspiration and diarrhea (Gavi & Hensley, 2008). Likewise, PEG tube feedings introduce the risk of blood pressure decreases or respiratory arrest while they are being placed surgically; however, these types of complications are rare (Hamel & Walter, 2007). According to Hamel and Walter (2007), "Other complications that occur with PEG tube placement include perforation of the gastrointestinal tract, infection of the abdominal cavity (known as peritonitis), bleeding, and local infection at the site of the tube placement" (p. 17). Many of the complications that are associated with tube feedings can be avoided by withholding enteral feedings for 2 hours prior to and following any administration of medications (Gavi & Hensley, 2010). In addition, nurses should ensure that patients are fed in a 30- to 45-degree semirecumbent body position to minimize the risk of aspiration (Gavi & Hensley, 2010). In this regard, Gavi and Hensley (2010) advises that, "[Patients] should remain in the position at least one hour after feeding is completed. Iso-osmotic feeds may be preferred since high-osmolality feeds can delay gastric emptying" (p. 37). Further, based on the reservoir limitations of the stomach, intermittent feeding (200-400 mL every 4 hours) is advised for gastric feedings (Gavi & Hensley, 2010).
What are some indications for inserting a urinary catheter? Why are hospitals trying to decrease the use of urinary catheters?
Some of the indications for inserting a urinary catheter include the following:
Acute urinary retention due to medication (e.g., anesthesia, opioids, paralytics), or nerve injury.
Acute bladder outlet obstruction due to severe prostate enlargement, blood clots, or urethral compression.
Need for accurate measurements of urinary output in the critically ill.
To assist in healing of open sacral or perineal wounds in incontinent patients.
To improve comfort for end of life, if needed.
Patient requires strict prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fracture).
Selected peri-operative needs including (a) urologic surgery or other surgery on contiguous (adjacent) structures of the genitourinary tract; (b) anticipated prolonged duration of surgery (Note: catheters placed for this reason should be removed in PACU); (c) large volume infusions or diuretics anticipated during surgery; and (d) need for intraoperative monitoring of urinary output (Indications for indwelling urinary catheter use, 2015).
Many hospitals are trying to reduce the use of urinary catheters, though, due to high incidence of catheter-associated urinary tract infections that can increase lengths of stay as well as morbidity and mortality (Smith, 2015).
Dosage calculation exercise:
A physician orders Ensure 120 ml q4h via NG tube x 3 feedings for a patient who is recovering from gastric surgery. Available are 4- and 8-ounce cans of Ensure, ready-to-use formula. Which can would you use? How many?
An Ensure 120-ml can contains about 4.05 ounces; therefore, 120-ml can of Ensure would be required for each of this patient's three feedings.
Identify one priority nursing diagnosis for Tony Vera. Diagnosis (from NANDA list) should include related to and as evidenced by (if applicable).
List 3 interventions for Tony Vera.
Rationale: Because Mr. Vera is at risk for deficient fluid volume, nurses should monitor intake and output.
Rationale: Mr. Vera's noncompliance with his prescribed medication regimen indicates ineffective health maintenance that requires patient education.
Rationale: Finally, Mr. Vera's impaired urinary function requires the use of an indwelling catheter.
Explain how you would evaluate the effectiveness of the nursing interventions you listed above.
A. An assessment of Mr. Vera's fluid intake and output could be used evaluate the effectiveness of this nursing intervention.
B. The patient's increased adherence to a prescribed medication regimen would be a measure of the effectiveness of this nursing intervention.
C. Finally, the level and frequency of Mr. Vera's urinary output would indicate the effectiveness of this nursing intervention.
Fessler, T. A. (2010, June). Gastric residuals -- Understand their significance to optimize care. Today's Dietitian, 12(5), 8.
Gavi, S. & Hensley, J. (2008, April). Management of feeding tube complications in the long-term care resident. Annals of Long-Term Care, 18(4), 37-39.
Giving medications through a feeding tube. (1999). Arbor Hospice. Retrieved from http://www.arborhospice.org/resources/pdf/file-20110413162339.pdf.
Hamel, R. P. & Walter, J. J. (2007). Artificial nutrition and hydration and the permanently unconscious patient: The Catholic debate. Washington, DC: Georgetown University Press.
Indications for indwelling urinary catheter use. (2015). Catheterout.org. Retrieved from… [END OF PREVIEW]
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