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Chapter 44
Nutrition /Naso-Gastric Tubes
ATI Skill Checklist N/G Tube Insertion
Gastrostomy Tube Feeding/Med
Administration
Managing Suction N/G Tube Decompression
Background

Food security is critical for all members of a
household.

Food holds symbolic meaning.

Medical nutrition therapy uses nutrition therapy and
counseling to manage disease.
 Type
1 diabetes mellitus
 Hypertension
 Inflammatory
 Enteral
bowel disease
nutrition (EN); parenteral nutrition (PN)
Case Study

Mrs. Gonzalez is a 65-year-old Hispanic
woman who comes to the emergency
department with slurred speech, right facial
droop, and weakness in her upper and lower
right-side extremities. She is admitted to the
hospital with a diagnosis of acute stroke.

She has a daughter and two teenage
grandchildren who live in another town
nearby.
Energy Requirements

Basal metabolic rate—the energy needed to
maintain life-sustaining activities for a specific
period of time at rest

Resting energy expenditure (REE) (aka resting
metabolic rate)—the amount of energy that an
individual needs to consume over a 24-hour period
for the body to maintain all of its internal working
activities while at rest

In general, when energy requirements are
completely met by kilocalorie intake in food,
weight does not change.
Scientific Knowledge Base:
Nutrients
Water
All cell function depends on a fluid environment.
Vitamins
Essential for metabolism
Water-soluble or fat-soluble
Minerals
Catalysts for enzymatic reactions
Macrominerals; trace elements
Digestion
Digestion
Absorption
Begins in the mouth and
ends in the small and
large intestines
Intestine is the primary
area of absorption.
Metabolism and
storage of nutrients
Elimination
Consist of anabolic and
catabolic reactions
Chyme is moved through
peristalsis and is
changed into feces.
Dietary Guidelines

Dietary reference intakes (DRIs)
 Acceptable
range of quantities of vitamins and
minerals for each gender and age group

Food guidelines
 Dietary

Guidelines, average daily consumption
Daily values
 Needed
protein, vitamins, fats, cholesterol,
carbohydrates, fiber, sodium, and potassium
Case Study (cont’d)



Mrs. Gonzales is awake and alert in her hospital
room, yet is drooling from the right side of her
mouth. When she tries to drink water, she starts to
cough. The physician has ordered nothing by mouth
(NPO).
Evaluation by the speech language pathologist (SLP)
indicates inadequate clearance of food and liquid
from the vocal folds and aspiration of thickened
liquids.
Mrs. Gonzalez has trouble swallowing with
oropharyngeal dysphagia. The SLP recommends
enteral feedings, and speech and swallowing
therapy to help her return to oral feedings.
Case Study (cont’d)

Matt is a nursing student assigned to Mrs. Gonzalez.
As he prepares to assess her, he recalls information
about the effects of dysphagia on nutrition and
rehabilitation. He will assess Mrs. Gonzales’ weight,
weight history, diet history, and cultural customs.

Matt knows to consult with a registered dietitian
(RD) to assess Mrs. Gonzales’s nutritional status and
interventions. Matt is responsible for inserting Mrs.
Gonzalez’s small-bore nasogastric feeding tube and
starting her tube feedings.
The RD has recommended continuous tube feeding
for 12 hours during the day.

Assessment

Screening a patient is a quick method of
identifying malnutrition or risk of
malnutrition using sample tools:
 Height
 Weight
 Weight
change
 Primary
diagnosis
 Comorbidities
 Screening
tools
Assessment (cont’d)

Anthropometry is a measurement system of the size
and makeup of the body.
 An
ideal body weight (IBW) provides an estimate
of what a person should weigh.
 Body
mass index (BMI) measures weight corrected
for height and serves as an alternative to
traditional height-weight relationships.

Laboratory and biochemical tests
Assessment (cont’d)

Dietary and health history
 Health
status; age; cultural background; religious
food patterns; socioeconomic status; personal
food preferences; psychological factors; use of
alcohol or illegal drugs; use of vitamin, mineral,
or herbal supplements; prescription or over-thecounter (OTC) drugs; and the patient’s general
nutrition knowledge

Physical examination

Dysphagia (difficulty swallowing)
Case Study (cont’d)

Assessment findings:
 Mrs.
Gonzales starts to cough when she tries to
drink water.
 Mrs.
Gonzales is unable to swallow and aspirates
pills and thickened liquid.
 Lung
sounds are clear. Respirations are regular at
12/min. She has no dyspnea. Oxygen saturation is
96% on room air.

Enteral nutrition will begin at 60 mL/hr.
Nursing Diagnosis
Risk for aspiration
Deficient knowledge
Diarrhea
Readiness for
enhanced
nutrition
Imbalanced
nutrition: more
than body
requirements
Feeding self-care Impaired swallowing
deficit
Imbalanced
nutrition: less
than body
requirements
Risk for imbalanced
nutrition: more than
body requirements
Case Study (cont’d)


Diagnosis: Risk for aspiration related to
impaired swallowing
Goals:
 Mrs.
Gonzales will receive adequate
nutrients through enteral tube feeding
without aspiration by the time of discharge.
 Mrs.
Gonzalez will regain swallowing ability
from speech therapy by the time of
discharge.
Planning

Nutrition education and counseling are important
for all patients to prevent disease and promote
health.

Refer to professional standards for nutrition.

Collaboration with a registered dietitian (RD) helps
develop appropriate nutrition treatment plans.

Considerations:

Perioperative food intake

Enteral and parenteral feedings

Assistive devices
Other Causes of Dysphagia
 Obstructive
lesions in the throat or
esophagus, such as tumors
 Central nervous system infections
 Head injury
 Cerebral palsy
 Parkinson's disease
 Huntington's disease
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Some causes of dysphagia include:

Myasthenia gravis

Amyotrophic lateral sclerosis (ALS)

Multiple sclerosis

Scleroderma

Infection with herpes simplex virus or yeast

Narrowing of the esophagus after infection or
irritation

Injury to the swallowing muscles from
chemotherapy and radiation for cancer
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Enteral Tube Feeding

Enteral nutrition (EN) provides nutrients into the GI
tract. It is physiological, safe, and economical
nutritional support.
 Nasogastric,
 Surgical
jejunal, or gastric tubes
or endoscopic placement
 Nasointestinal
 Gastrostomy
 Jejunostomy
 PEG
(percutaneous endoscopic gastrostomy)
 PEJ
(percutaneous endoscopic jejunostomy)
 Risk
of aspiration
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•Enteral Tubes
Most health care settings use small-bore feeding tubes because they create less
discomfort for a patient. For the adult, most of these tubes are 8- to 12-French and 36 to
44 inches long.
A stylet is often used during insertion of a small-bore tube to stiffen it. The stylet is
removed when correct positioning of the feeding tube is confirmed.
NG TUBE INSERTION
Ear lobe to xiphoid
process
Ear lobe to Nose
Tip
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Chest Xray Representing a Properly placed NG tube
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Chest xray NG tube in left main stem Bronchi
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pH Measurement for Tube Location
See Box 44-13 on text p. 1020
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Benzocaine Spray
Viscous Lidocaine
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TYPES OF NASOGASTRIC TUBES

The first nasogastric tubes were made of soft rubber.
Recently, tubes have been made of silastic and
polyethylene compounds.

These tubes can be inserted more easily and also cause
fewer medical problems for the patient. There are fewer
instances of inflamed tissues.
With the exception of this change, nasogastric tubes are
very much the same today as they have been for the last
three decades.

The most commonly used nasogastric tube is the Levin
tube.

Other nasogastric tubes include the Salem-sump tube, the
Miller-Abbott tube, and the Cantor tube.
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The Levin Tube




The actual tubing is referred to as lumen.
The Levin tube is a one-lumen nasogastric
tube.
The Salem-sump nasogastric tube is a
two-lumen piece of equipment; that is, it
has two tubes.
The Levin tube is usually made of plastic
with several drainage holes near the
gastric end of the tube. There are
graduated patient depth markings.
This nasogastric tube is useful in instilling
material into the stomach or suctioning
material out of the stomach.
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Case Study (cont’d)



Nutritional management

Insert feeding tube as ordered.

Initiate enteral feeding as prescribed.

Advance tube feeding as tolerated; monitor for tolerance.
Aspiration precautions

Position Mrs. Gonzalez with head of bed elevated a
minimum of 30 degrees.

Check tube placement every 4 to 6 hours.

Check gastric residual volume every 4 hours.
Continue with speech therapy.
ENTERAL TUBE FEEDING COMPLICATIONS
TABLE 44-7 (Pg.1022)

Pulmonary Aspiration

Diarrhea

Constipation

Tube Occlusion

Tube Displacement

Abdominal Cramping-Nausea/Vomiting

Delayed Gastric Emptying

Serum Electrolyte Imbalance

Fluid Overload

Hyperosmolar Dehydration
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Quick Quiz!
2. You receive an order to begin enteral tube
feedings. The first step is to
A. Place the patient in a prone position.
B. Irrigate the tube w/normal saline.
C. Check to see that the tube is properly
placed.
D. Introduce a small amount of fluid into the
tube before feeding.
Parenteral Nutrition

Nutrients are provided intravenously.

Patients unable to digest or absorb enteral nutrition
or are in highly stressed physiological states:

Sepsis

Head injury

Burns

Peripheral or central line

Initiating parenteral nutrition

Preventing complications
Restorative and Continuing Care

Medical nutrition therapy (MNT)
 Specific
nutritional therapy usage for
treating illness, injury, or a certain condition
 Necessary
for
Metabolizing
Correcting
certain nutrients
nutritional deficiencies
Eliminating
foods that worsen disease
states
 Most
effective with collaborative health care
team and dietitian
Case Study (cont’d)
 What
nursing actions are appropriate
for evaluating whether goals have been
met?
Consider
Check
the patient’s perspective.
measurable outcomes.
Consult
with interdisciplinary staff.
Evaluation
 Multidisciplinary
collaboration remains
essential in providing nutritional
support.
 Changes
in condition indicate a need to
change the nutritional plan of care.
 Consider
the limits of patients’
conditions and treatments, their
dietary preferences, and their cultural
beliefs when evaluating outcomes.
Case Study (cont’d)

Matt sees Mrs. Gonzalez before discharge to a
restorative care facility for rehabilitation before
returning home. Mrs. Gonzalez now is able to
consume all of her required nutrients with a ground
diet and nectar-thickened liquids. Matt removes the
feeding tube in preparation for her transport to the
new facility.

Matt advises Mrs. Gonzalez to continue the care plan
and emphasizes that it is important to continue
speech therapy.
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NG Tubes for Decompression
Refer to ATI (Accepted Practice)
 N/G intubation is used for several purposes:

to decompress the stomach and remove gas and
fluid,

to lavage the stomach to remove ingested toxins,

to diagnose problems with GI motility,

to treat an obstruction,

to compress a bleeding site,

to aspirate contents for a gastric analysis,

and to administer contrast for a radiographic study.
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The Miller-Abbott Tube
(Active Gastric Hemorrhage)
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NG Tubes for Decompression

Gastric decompression is indicated for
obstruction or paralytic ileus and when surgery
is performed on the stomach or intestine.

The tube usually remains in place until normal
bowel function returns as evidenced by normal
bowel sounds on auscultation and/ or when the
pt. begins to pass flatus.
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The Salem-Sump Tube

This nasogastric tube is a two-lumen
piece of equipment. It has a drainage
lumen and a smaller secondary tube that
is open to the atmosphere.

The major advantage of this two-lumen
tube is that it can be used for continuous
suction.

The continuous airflow reduces the
frequency of stomach contents being
drawn up into the whole of the lumen
which is in the patient's stomach.
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NG Tubes for Decompression

With gastric decompression, stomach contents are
removed to relieve the stomach and intestines of
the pressure caused by the accumulation
gastrointestinal air and fluid.

The N/G tube is connected to suction to facilitate
decompression by removing the contents.
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Postoperative Gastrointestinal Discomfort

Postoperative gastrointestinal discomfort is not
new. The earliest written records described an
unchanging physiological response following any
type of surgery, with greater severity after
laparotomy.

Clinically, there are three typical consequences
of surgery, namely dilatation of the stomach, ileus
and PONV. (Post-Op Nausea & Vomiting)
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Postoperative Gastrointestinal Discomfort

Dilatation of the stomach is related to the common
postoperative increase in swallowing [1]. Air carried
into the stomach with each swallow induces gastric
discomfort, and when present in great quantities the
air passes into the intestine, resulting in abdominal
distension.

The greatest incidences were found in patients who
had undergone surgery to the biliary tract or uterus. In
the majority of the cases, distension was apparent
after 24 hours and the usual duration was 48 to 72
hours [2].
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Postoperative Gastrointestinal Discomfort

Decompression relieves gastric discomfort, but the
irritating presence of the tube promotes swallowing.

In any case, these physiological events must be
distinguished from acute gastric dilatation and acute
colonic pseudo-obstruction, which are responsible for
major abdominal distension in very specific
circumstances.
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Mechanisms of postoperative
gastrointestinal discomfort
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NG Tubes for Decompression
 For
some patients the tube is placed
during surgery and used post-op for
gastric decompression. This is usually
used for patients who undergo extensive
surgery or who are at a high risk for
prolonged postoperative ileus.
 Follow
the surgeon’s post op order for
specific instruction on suction,
irrigation etc.
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GASTRIC LAVAGE

Gastric Lavage is the irrigation of the
stomach.
This is usually performed is acute care
settings where poisonings or drug overdoses
for which swift removal of stomach contents
is required.
 In this situation an orogastric or nasogastric
tube is inserted both to aspirate gastric
contents and to instill a rinsing solution into
the stomach to dilute the toxic substance.

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BIG RED
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GASTRIC LAVAGE
Patients who have gastric bleeding are
sometimes treated with iced saline lavage,
which involves instillation and aspiration of iced
saline through an N/G tube to empty the
stomach of blood and to slow the bleeding
(vasoconstriction) at its source. (Controversial
due to the Vasovagal response which increases
acid reflux)
 Norepinephrine is sometimes used as a
vasoconstrictor at the site but the hypertensive
response must be closely monitored.
 Lavage may also be used as therapy for hypo or
hyperthermia to help stabilize body
temperature.

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