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Common types of tubes used in the clinical setting
Assessment points related to the specific type of tube
Procedures for insertion of a particular tube Standard (universal) precautions Handling infectious materials
Verifying correct placement and procedures for administering medications or feedings, if appropriate
Interventions related to the care of the client
Interventions associated with complications or emergencies that may occur
Client/family education regarding care at home
DESCRIPTION◦ Short tubes used to intubate the stomach◦ Inserted from the nose to the stomach
LEVINE◦ Single-lumen nasogastric tube◦ Used to remove gastric contents via intermittent
suction or to provide tube feedings
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.
SALEM SUMP◦ Double-lumen nasogastric tube with an air vent ◦ Used for decompression with continuous suction◦ Air vent is not to be clamped and is to be kept
above the level of the stomach◦ If leakage occurs through the air vent, instill 30 ml
of air into the air vent and irrigate the main lumen with normal saline (NS)
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.
Place the client in high-Fowler’s position Measure from tip of nose to earlobe to
xiphoid process to determine the length of insertion and mark with tape
Lubricate tube about 3 inches with a water-soluble jelly only (oil-soluble is not used), to prevent the development of pneumonia if the tube accidentally slips into the bronchus
Instruct the client to bend the head forward, which closes the epiglottis and opens the esophagus
Insert into nostril, advance backward and through the nasopharynx
Have the client take a sip of water and advance tube as the client swallows
Do not force the tube If the client experiences any respiratory
distress (coughing or choking) during insertion, pull back on the tube and wait until the distress subsides
Advance until taped mark is reached; tape in place when correct placement is confirmed
If feedings are prescribed, x-ray confirmation should be done prior to initiating feedings
When gastrointestinal (GI) tubes are attached to suction, suction may be continuous or intermittent, with a pressure not exceeding 25 mmHg as prescribed by the physician
From Perry, A. & Potter, P. (2002). Clinical nursing skills and techniques, ed 5, St Louis: Mosby.
The most reliable method to determine placement is by x-ray
Assess placement every 4 hours and before administering feedings or medications
Assess placement by aspirating gastric contents and measuring the pH, which should be 4 or less (pH values greater than 6 indicate intestinal placement)
Inserting 5 to 10 ml of air into the NG tube and listening for the rush of air over the stomach with a stethoscope is an alternative method for assessing placement, but is not as reliable as an x-ray or checking gastric pH
Check residual volumes every 4 hours, before each feeding, and before giving medications
Aspirate all stomach contents (residual) and measure amount
Reinstill residual feeding to prevent excessive fluid and electrolyte losses unless the residual volume appears abnormal
Performed every 4 hours to check the patency of the tube
Assess placement before irrigating Gently instill 30 to 50 ml of water or normal
saline (NS) (depending on agency policy) with an irrigation syringe
Pull back on the syringe plunger to withdraw the fluid to check patency; repeat if tube remains sluggish
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 as it is being removed)
TUBES◦ Nasogastric◦ Nasoduodenal or nasojejunal◦ Gastrostomy◦ Jejunostomy
From Perry, A. & Potter, P. (2002). Clinical nursing skills and techniques, ed 5, St Louis: Mosby.
From Perry, A. & Potter, P. (2002). Clinical nursing skills and techniques, ed 5, St Louis: Mosby.
TYPES OF FEEDINGS◦ Bolus◦ Continuous◦ Cyclical
BOLUS ◦ Resembles normal meal feeding patterns◦ Can be administered via a syringe or via an
intermittent feeding◦ With an intermittent feeding, approximately 300
to 400 ml of formula is administered over a 30- to 60-minute period every 3 to 6 hours
From Perry, A. & Potter, P. (2002). Clinical nursing skills and techniques, ed 5, St Louis: Mosby.
CONTINUOUS◦ Administered continuously for 24 hours◦ An infusion pump regulates the flow
CYCLICAL◦ Administered either in the daytime or nighttime
for 8 to 16 hours◦ An infusion pump regulates the flow◦ Feedings at night allow for more freedom during
the day
From Perry, A. & Potter, P. (2002). Clinical nursing skills and techniques, ed 5, St Louis: Mosby.
Position the client in high-Fowler’s and on the right side if comatose
Warm feeding to room temperature to prevent diarrhea and cramps
Aspirate all stomach contents (residual), measure the amount, and return the contents to the stomach to prevent electrolyte imbalances
Check physician’s order and agency policy regarding residual amounts; usually if the residual is less than 100 to 150 ml, feeding is administered; if greater than 150 ml, hold the feeding
Assess tube placement by aspirating gastric contents and measuring the pH (should be 4 or less)
Assess bowel sounds; hold feeding and notify the physician if bowel sounds are absent
Use a feeding pump for continuous or cyclical feedings
For bolus feeding, leave the client in a high-Fowler’s position for 30 minutes after feeding
For a continuous or cyclical feedings, keep the client in a semi-Fowler’s position at all times
Change the feeding container and tubing every 24 hours
Do not hang more solution than will be required for a 4-hour period to prevent bacterial growth
Check the expiration date on the formula prior to administering
Shake the formula well prior to inserting into container
Always assess placement of the tube prior to feeding
Always assess bowel sounds; do not administer any feedings if bowel sounds are absent
If an obstruction occurs, try flushing with water, saline, cranberry juice, ginger ale, or cola, if not contraindicated, after checking placement
Add a drop of methyline blue to the feeding, particularly with clients who have endotracheal or tracheal tubes; suspect tracheoesophageal fistula when blue gastric contents appear in tracheal excretion and if this is noted, notify the physician immediately
Administer feeding at prescribed rate, or via gravity flow (intermittent, bolus feedings) with a 60-ml syringe with the plunger removed
Gently flush with 30 to 50 ml of water or normal saline (depending on agency policy) with the irrigation syringe after the feeding
Aspiration Vomiting Diarrhea Clogged tube
Verify tube placement Do not administer feeding if residual is
greater than 150 ml Keep the head of the bed elevated If aspiration occurs, suction as needed,
assess respiratory rate, auscultate lung sounds, monitor temperature for aspiration pneumonia, and prepare to obtain chest radiograph
Administer feedings slowly, and for bolus feedings, make the feeding last for 30 minutes
Do not allow feeding to run dry Do not allow air to enter the tubing Administer feeding at room temperature Elevate the head of the bed Administer antiemetics as prescribed If client vomits, place in side-lying position
Use fiber-containing feedings Administer feeding slowly and at room
temperature
Use liquid forms of medication, if possible Flush the tube with 30 to 50 ml of water or
NS (depending on agency policy) before and after medication administration and before and after bolus feeding
Flush with water every 4 hours for continuous feeding
Crush medications or use elixir forms of medications; assure that the medication ordered can be crushed or that the capsule can be opened
Dissolve crushed medication or capsule contents in 5 to 10 ml of water
Check placement and residual prior to instilling medications
Draw up the medication into a catheter tip syringe, clear excess air, and insert medication into the tube
Flush with 30 to 50 ml of water or NS (depending on agency policy)
Clamp the tube for 30 to 60 minutes (depending on medication and agency policy)
DESCRIPTION◦ Passed nasally into the small intestine◦ Used to decompress the bowel or to remove
intestinal contents◦ Enters the small intestine through the pyloric
sphincter because of the weight of a small bag of mercury at the end
Cantor and Harris tube Miller-Abbott tube
Single-lumen tube with a reservoir for 5 to 10 ml of mercury located at its tip, below the level of the drainage holes
Mercury is inserted before the tube is passed through the nose, making the procedure uncomfortable
The Harris tube is also used for lavage and suction
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.
A double-lumen tube One lumen is for the instillation of mercury
once the tube is in the stomach, and the other is for irrigation or drainage
From Monahan, F. & Neighbors, M. (1998) Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.
IMPLEMENTATION◦ Assess physician’s orders and agency policy for
advancement and removal of tube◦ Position client on the right side to facilitate
passage of the mercury weights within the tube through the pylorus of the stomach and into the small intestine
◦ Do not secure the tube to the face with tape until it has reached final placement (may take several hours) in the intestines
◦ X-ray is performed to verify desired placement
IMPLEMENTATION◦ Monitor drainage from the tube◦ If the tube becomes blocked, notify the physician;
a small amount of air injected into the lumen may be prescribed to clear the tube
◦ Assess the abdomen and measure abdominal girth
IMPLEMENTATION◦ To remove the tube, the mercury and air are
removed from the balloon portion of the tube with a 5-ml syringe; the tube is gradually removed (6 inches every hour) as prescribed by the physician
◦ Dispose the mercury in the appropriate manner as per agency policy
DESCRIPTION◦ Used to apply pressure against esophageal veins
to control bleeding◦ Not used if the client has ulceration or necrosis of
the esophagus or had previous esophageal surgery
TYPES◦ Sengstaken-Blakemore tube◦ Minnesota tube
Triple-lumen gastric tube with an inflatable esophageal balloon, an inflatable gastric balloon, and a gastric aspiration lumen
The gastric balloon applies pressure at the cardioesophageal junction to directly compress gastric varices and to decrease blood flow to esophageal varices; traction is applied to maintain the gastric balloon in place
The esophageal balloon directly compresses esophageal varices
If bleeding is not stopped with inflation of the gastric balloon, the esophageal balloon is inflated to 25 to 45 mmHg
An x-ray of upper abdomen and chest confirms placement
Gastric contents are aspirated by gastric lavage or intermittent suction via the gastric aspiration port
A nasogastric tube is also inserted in the opposite naris to collect secretions that accumulate above the esophageal balloon
From Monahan, F. & Neighbors, M. (1998), Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.
Four-lumen gastric tube A modified Sengstaken-Blakemore tube with
an additional lumen for aspirating esophagopharyngeal secretions
IMPLEMENTATION◦ Check patency and integrity of all balloons prior
to insertion◦ Label each lumen◦ Place the client in the upright or Fowler’s position
for insertion◦ Prepare for x-ray immediately after insertion to
verify placement◦ Maintain head elevation once the tube is in place
IMPLEMENTATION◦ 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 tubes to deflate balloons
◦ Release esophageal pressure as prescribed and per agency policy to prevent ulceration or necrosis of the esophagus
IMPLEMENTATION◦ Monitor for increased bloody drainage, which may
indicate persistent bleeding ◦ Monitor for signs of esophageal rupture, which
includes a drop in blood pressure, increased heart rate, or back and upper abdominal pain
◦ Esophageal rupture is an emergency and must be reported to the physician immediately
DESCRIPTION◦ Used to remove toxic substances from the
stomach
LAVACUATOR ◦ 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
EWALD’S◦ Reusable single-lumen large tube used for rapid
one-time irrigation and evacuation
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.