gastrointestinal nursing

1. NG tube (Nasogastirc tubes)

  • The tube is used to decompress the stomach by removing fluids or gas to promote abdominal comfort. The tube is used to administer medications to clients who are unable to swallow. The tube is used to provide nutrition by acting as a temporary feeding tube. The tube is used to irrigate the stomach and remove toxic substances, such as poisoning.
① Levin tube (L-tube) – A plastic or rubber single-lumen tube with a solid tip that may be inserted into the stomach via the nose or mouth.
② salem sump tube – A salem sump is a double-lumen tube with an air vent used for decompression with intermittent continuous suction. The air vent on a Salem sump tube is not to be clamped and is to be kept above the level of the stomach. If leakage occurs through the air vent, instill 30mL of air into the air vent and irrigate the main lumen with NS.
  • ★ intubation procedure: ① Explain the procedure and its potential discomfort to the client. ② Position the client with pillows behind the shoulders. ③ Determine which nostril is more patent. ④ Measure the length of the tube from the bridge of the nose to the earlobe to the xiphoid process and indicate this length with a piece of tape on the tube. ⑤ Lubricate the tip of the tube with a water-soluble lubricant. ⑥ Gently insert the tube into the nasopharynx and advance the tube. Tilt the head back slightly and inserts the tube. (cough와 gag는 기대소견) ⑦ When the tube nears the back of the throat, instruct the client to swallow or drink sips of water. If resistance is met, then slowly rotate and aim the tube downward and toward the closer ear. In the intubated or semiconscious client, flex the head toward the chest while passing the tube. When the tube curves at the pharynx, tilt the head forward to close trachea and open the esophagus. ⑧ Immediately withdraw the tube if any change is noted in the client’s respiratory status. ⑨ Secure the tube to the client’s nose with adhesive tape and to the client’s gown. ⑩ Following insertion, obtain an abdominal x-ray study to confirm the placement of the tube. ⑪ Before the instillation of any substance through the tube, aspirate stomach contents, and test the pH. (pH 5 이하) ⑫ Inject 5 to 10 cc air and listen for the rush of air. (더 이상 쓰지 않음) ⑬ Instruct the client about the movement to prevent nasal irritation and dislodgment of the tube. ⑭ On a daily basis, remove the adhesive tape that is securing the tube to the nose and clean and dry the skin, assessing for excoriation. Then reapply the tape.
  • irrigation procedure: ① Assess placement before irrigating. ② Gently instill 30 to 50 mL of water or NS with an irrigation syringe. ③ Pull back on the syringe plunger to withdraw the fluid to check patency. ④ Repeat if the tube flow is sluggish. ⑤ Perform irrigation every 4 hours to assess and maintain the patency of the tube.
  • ★ administration of feedings: ① Check the HCP’s prescription and agency policy regarding residual amounts. Usually, if the residual is less than 250 mL, feeding is administered. Large volume aspirates indicate delayed gastric emptying and place the client at risk for aspiration. Reinstill residual contents to prevent excessive fluid and electrolyte losses. ② Assess bowel sounds. Hold the feeding and notify the HCP if bowel sounds are absent. ③ Position the client in a high-Fowler’s position. If comatose, place in high Fowler’s and on the right side. ④ Assess tube placement. ⑤ Warm the feeding to room temperature to prevent diarrhea and cramps. ⑥ For bolus feeding, maintain the client in a high Fowler’s position for 30 minutes after the feeding. For continuous feeding, keep the client in a semi-Fowler’s position at all times. ⑦ Administer the feeding at the prescribed rate or via gravity flow (at the 18-inch height from the stomach) with a 50 to 60 mL syringe with the plunger removed. ⑧ Gently flush with 30 to 50 mL of water with the irrigation syringe after the feeding. (Normal saline 시 crystallization됨.) ⑨ If the client vomits, stop the tube feeding and place the client in a side-lying position. Suction the client as needed. ⑩ Change the feeding container and tubing every 24 hours. Do not hang more solution than required for a 4 hours period to prevent bacterial growth.
  • administering medication : ① Check the HCP’s prescription. ② Prepare the medication for administration. ③ Ensure that the medication prescribed can be crushed or if it is a capsule that can be opened. Use elixir forms of medications if available. ④ Dissolve crushed medication or capsule content in 15 to 30mL of water. ⑤ Verify the client’s identity and explain the procedure to the client. ⑥ Check tube placement and residual contents before instilling the medication. Check for bowel sounds. ⑦ Draw up the medication into a catheter tip syringe, clear excess air from the syringe, and insert the medication into the tube. ⑧ Flush with 30 to 50 mL of water or NS, depending on agency policy. ⑨ Clamp the tube for 30 to 6o minutes, depending on medication and agency policy. ⑩ Document the administration of the medication and any other appropriate information.
  • removal procedure: Ask the client to take a deep breath and hold. Remove the tube slowly and evenly over the course of 3 to 6 seconds. Coil the tube around the hand while removing it.
  • clogging 시: warm N/S, pancreatic lipase
  • silent aspiration의 징후: sudden M/S change

2. intestinal tubes

  • The intestinal tube is passed nasally into the small intestine.
① Cantor tube – A single lumen long tube with a small inflatable bag at the distal end. A special substance is injected with a needle and syringe into the bag of the tube.
② Miller-Abbott tube – A long double-lumen tube used to drain and decompress the small intestine. One lumen leads to a balloon that is filled with a special substance once it is in the stomach. The second is for irrigation and drainage.

3. esophageal tube

  • May be used to apply pressure against bleeding esophageal veins to control the bleeding when other interventions are not effective or they are contraindicated. Not used if the client has ulceration or necrosis of the esophagus or has had previous esophageal surgery because of the risk of rupture.
① SB tube

(Sengstaken-Blakemore tube)

– The SB tube, used only occasionally, is a triple lumen gastric tube with an inflatable esophageal balloon (compresses esophageal varices), an inflatable gastric balloon (applies pressure at the cardio esophageal junction), and a gastric aspiration lumen.
② Minnesota tube – More commonly used is the Minnesota tube, which is a modified SB tube with an additional lumen for aspirating esophagopharyngeal secretions.
  • interventions: Check the patency and integrity of all balloons before insertion. Double-clamp the balloon ports to prevent air leaks. Keep scissors at the bedside at all times. Monitor for respiratory distress, and if it occurs, cut the tubes to deflate balloons. Monitor for signs of esophageal rupture, which includes a drop in BP, increased HR, and back and upper abdominal pain.

4. lavage tube

  • Used to remove toxic substances from the stomach
① lavacuator tube – The lavacuator is an orogastric tube with a large suction lumen and a smaller lavage-vent lumen that provides continuous suction. Irrigation solution enters the lavage lumen while stomach contents are removed through the suction lumen.
② ewald tube – A single-lumen large tube used for rapid one-time irrigation and evacuation.

5. T-tube

  • A T-tube is placed after surgical exploration of the common bile duct. The tube preserves the patency of the duct and ensures drainage of bile until edema resolves and bile is effectively draining into the duodenum. A gravity drainage bag is attached to the T-tube to collect the drainage.
  • Place the client in a semi-Fowler’s position to facilitate drainage. Keep the drainage system below the level of the gallbladder. Monitor the output amount, color, consistency, and odor of the drainage. Report sudden increases in bile output to the HCP. Monitor for four odor and purulent drainage and report its presence to the HCP. Monitor for inflammation and protect the skin from irritation. Avoid irrigation, aspiration, or clamping of the T-tube without an HCP’s prescription. As prescribed, clamp the T-tube before a meal and observe for abdominal discomfort and distention, nausea, chills, or fever. Unclamp the tube if nausea or vomiting occurs.

6. PEG tube

  • tube와 skin 사이에 거즈 두지 않기.

7. enema

  • position : Lt sim’s position
  • warm or tepid water
  • tube에서 air를 뺀 후, 배꼽을 향해 3 to 4 inch 정도 삽입
  • enema can을 들 때
    rectum에서부터 12 inch 이상 올리지 말기
    mattress에서부터 18 inch 이상 올리지 말기
  • distention이 되었다면 정상
  • cramping or pain 시 stop infusing the solution for 30 seconds, then resume at a slower rate
  • enema 금기 : 녹내장, 뇌압이 높을 때, s/p 전립선 수술, s/p 직장 수술

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