The nasal route is the preferred method for passing a tube if the patients’ nose is intact. The type of tube used depends on the reason for placing the tube. Smaller tubes are used for feeding and larger tubes are used for decompression.

Nasogastric tubes-

• Levin can be plastic or rubber, 125 cm in length, 14-18 size, single lumen – decompression and feeding
• Gastric sump Salem- 120 cm, 12-18 size, double lumen used for decompression
• Sengstaken-Blakemore- is rubber, triple lumen, contains both a gastric decompression lumen and one for post op feedings
• Double lumen tubes- one serves as a vent, allows the infusion of 2 different fluids at once, a common problem though is leakage from the vent lumen. For this reason the nurse should keep the vent above the level of the patients’ stomach.

• Gastrostomy tubes are used for long term feedings.

• The client has a transabdominal opening into the stomach that provides long term access for administering fluids and liquid nourishments.

• Can be done surgically or endoscopically.

• Surgical placement involves a laparotomy and surgical creation of an external stoma where a gastrostomy tube is placed.

• When the client is receiving tube feedings the nurse needs to determine why it is needed.
• Evaluate renal function and check for digestive issues.
• Assess previous stool patterns weight, and any vomiting.
• The nurse should ensure that the lungs remain free of liquid substances, that the client doesn’t acquire an infection, and I & O.
• Keep the mucous membranes moist because clients tend to have a dry mouth from breathing and remaining NPO.
• Frequent oral care is recommended.

• Percutaneous endoscopic gastrostomy (PEG) – an endoscope is introduced orally and advanced into the stomach so that the physician can see the correct location of the tube.

• MD inserts Peg and a trained nurse perform replacement of the PEG.

• This procedure can be done on the bedside with minimal sedation of the patient. Endoscopic placement is preferred to surgical laparotomy.
• Except when the client is morbidly obese, has ascites, or has had previous gastric surgery.
• If the condition improves the tube is then removed.
• To stabilize the tube most gastrostomy tubes have an external bumper and a firm internal bumper or an inflatable balloon.
• Advantage of the firm internal bumper is that it is difficult to dislodge. Disadvantage is that it might be painful to remove when replacement is needed.
• Advantage of the balloon is that it is mostly painless and easy to replace. Disadvantage is ease of displacement and loss of fluid resulting in leakage.

Complications from PEG tubes- note how the PEG is stabilized.
• There is often an internal and an external bumper.
• Internal prevents tube to be dislodged and the external secures the tube to the abdominal wall and prevents tube from migrating. Some of these problems can occur:
• Bumpers too tight: pressure ulcer on the abdomen, internal bumper becomes buried in the abdominal wall leading to GI bleed, perforation, or peritonitis

• Bumpers too loose: movement of the tube leading to irritation, ulceration of the tract or both, dislodgement

• Always inspect insertion site for signs of irritation, infection, drainage, or gastric leakage. Although a new PEG may have slight amount of bleeding, mucus, or both.

• New tubes are usually taped or sutured until it heals.

Types of feedings and feeding methods:

Liquid nourishment is provided by bolus, intermittent, cyclic, or continuous methods.
• Depending on orders the feeding tube is flushed with water to ensure patency.

• Bolus tube feeding- introduces about 250 to 400 mL of formula though the tube in a short time of about 15-30 minutes. Administered by a syringe or gravity flow system attached to the end of the tube.

• Intermittent tube feeding- delivers between 250-400 mL formula over 30 to 60 minutes. Delivered by gravity flow system or electronic feeding pump.

• Continuous tube feeding- delivers formula at lower rates of about 1.5 mL per minute over a long time about 12-24 hours. Delivered by gravity flow system or an electronic feeding pump

• Cyclic tube feeding- allows formula to be administered continuously for 8 to 12 hours during sleep followed by a 16 to 12 hour pause.

• Always ensure adequate nutrition during weaning from tube to oral feeding.

• Alternated with oral food intake until client can tolerate oral nutrition completely.
posted by Candy – SVN