PROCEDURE FOR INSERTING AN ORAL/NASAL  SMALL BOWEL FEEDING TUBE IN CCTC
 1. Select Patient  <ul><li>Attempts should be made to insert all feeding tubes into the small bowel during initial placem...
Contraindications to oral/nasal tube placement: <ul><li>Esophageal varices  </li></ul><ul><li>Esophageal surgery (e.g., es...
RATIONALE FOR PROCEDURE #1 <ul><li>  1.  A feeding tube that sits in the small bowel results in improved tolerance of feed...
 2. Obtain Order <ul><li>Rule out contraindications to feeding tube insertion and check for allergies/sensitivity to eryth...
RATIONALE FOR PROCEDURE # 2 <ul><li>  2.  Erythromycin has been shown to stimulate gastric motility and facilitate gastric...
 3. Collect Supplies   <ul><li>Feeding tube  </li></ul><ul><li>60cc syringe  </li></ul><ul><li>Water for flushing feeding ...
 4. Prepare for Insertion <ul><li>Explain procedure to patient and family. </li></ul><ul><li>Wash hands and put on non-ste...
RATIONALE FOR PROCEDURE # 4 <ul><li>Preparation reduces anxiety and provide an opportunity to answer questions.  </li></ul...
 5. Adjust Bed <ul><li>Patient should be in supine, upright position with HOB ~45 degrees as tolerated (unless contraindic...
RATIONALE FOR PROCEDURE # 5 <ul><li>To facilitate the initial advancement into the stomach.  </li></ul>
6. Measure Placement <ul><li>Remove existing nasogastric or oral tube.  </li></ul><ul><li>Measure the tip of the feeding t...
RATIONALE FOR PROCEDURE # 6 <ul><li>This measurement will indicate when the feeding tube should have reached the stomach.I...
7. Prepare Feeding Tube <ul><li>Dip the tip of the feeding tube in water.  </li></ul><ul><li>Secure stylet tightly into th...
RATIONALE FOR PROCEDURE # 7 <ul><li>The stylet provides tube stiffness to facilitate advancement. Flushing activates the l...
8. Begin Insertion <ul><li>Connect the empty luer lock syringe to the guidewire end of the feeding tube. Be sure the feedi...
<ul><li>If the patient has an NG/OG tube in place, identify whether gastric drainage will continue following small bowel p...
<ul><li>Gently insert the well lubricated tip of the feeding tube into one nare. If the tube cannot be advanced into the n...
<ul><li>Once the tube is in the pharynx, ask the patient (if able) to swallow and while slowly advancing the tube. If the ...
<ul><li>When the tube has been advanced to the ~30cm mark, try to aspirate. If you aspirate air, you are likely in the tra...
RATIONALE FOR PROCEDURE # 8 <ul><li>If the NG is at the pylorus, it may interfere with the placement of the feeding tube. ...
9. Advance to Lower Esophagus  <ul><li>Advance the tube to predetermined marking (35-40 cm).  </li></ul>
RATIONALE FOR PROCEDURE # 9 <ul><li>Airway placement should be ruled out before the tube is advanced into the stomach or s...
10. Confirm Placement in the GI tract  <ul><li>Obtain a CHEST X-ray. Have X-ray assessed to RULE OUT airway placement. </l...
RATIONALE FOR PROCEDURE # 10 <ul><li>Identify the carina on the X-ray. Follow the feeding tube. If the feeding tube follow...
<ul><li>pH has been reported to be a useful method for assessing tube placement, however, it can not be used to confirm pl...
11. Position the Patient for Advancement of the Tube into the Small Bowel <ul><li>1. Following radiographic confirmation t...
RATIONALE FOR PROCEDURE # 11 <ul><li>The stomach empties toward the right into the duodenum (5).  </li></ul>
12. Administer Prokinetic Agent <ul><li>Once airway placement has been ruled out, administer 500mg erythromycin in 100 ml ...
RATIONALE FOR PROCEDURE # 12 <ul><li>Peripheral administration can cause phlebitis. </li></ul><ul><li>Intravenous erythrom...
13. Introduce Air Into the Stomach <ul><li>Within 30 minutes following completion of the erythromycin bolus, or 10 minutes...
RATIONALE FOR PROCEDURE # 13 <ul><li>Air insufflation facilitates opening of the pyloric bulb and stimulates gastric motil...
14. Advance Tube into Small Bowel <ul><li>Begin advancing tube with a twisting, corkscrew-like motion in 10cm increments. ...
RATIONALE FOR PROCEDURE # 14 <ul><li>The twisting motion turns the tip of the tube, helping it find the bulb of the pyloru...
15. Auscultate <ul><li>While auscultating over the right upper quadrant, inject 20cc of air.  Do the same over the epigast...
RATIONALE FOR PROCEDURE # 15 <ul><li>You will hear the air bolus loudest and with a high-pitch over the RUQ if the feeding...
16. Secure the Tube <ul><li>Secure the feeding tube with tape, being careful not to put pressure on the patient's nares wi...
RATIONALE FOR PROCEDURE # 16 <ul><li>Documentation on the Kardex provides a reference to identify if the tube has been pul...
17. Confirm Placement Prior to Feeding <ul><li>Obtain an ABDOMINAL X-ray for verification of feeding tube placement.  </li...
RATIONALE FOR PROCEDURE # 17 <ul><li>Xray confirmation is mandatory prior to administration of medications, flush solution...
18. Remove Guidewire <ul><li>Once placement has been verified by the physician, flush the guidewire with saline and gently...
RATIONALE FOR PROCEDURE # 18 <ul><li>Do not reinsert guidewire  following removal, as the guidewire could puncture the fee...
19. Document Procedure <ul><li>Document procedure in the AI record. Record feeding tube size and length, final placement m...
RATIONALE FOR PROCEDURE # 19 <ul><li>To communicate findings and meet documentation standards.  </li></ul><ul><li>http://n...
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Procedure for inserting an oral/nasal small bowel feeding tube in CCTC

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Procedure for inserting an oral/nasal small bowel feeding tube in CCTC

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Procedure for inserting an oral/nasal small bowel feeding tube in CCTC

  1. 1. PROCEDURE FOR INSERTING AN ORAL/NASAL SMALL BOWEL FEEDING TUBE IN CCTC
  2. 2.  1. Select Patient <ul><li>Attempts should be made to insert all feeding tubes into the small bowel during initial placement, using this procedure. </li></ul><ul><li>Exception: For patients previously tolerating gastric feeding and requiring frequent feeding tube reinsertions gastric placement is acceptable. </li></ul><ul><li>A minimum of two xrays is required for safe placement of all feeding tubes. If initial attempts to place a feeding tube into the small bowel results in gastric placement, initiate feeding via the gastric route, assess for tolerance and re-evaluate the need for small bowel placement. </li></ul>
  3. 3. Contraindications to oral/nasal tube placement: <ul><li>Esophageal varices </li></ul><ul><li>Esophageal surgery (e.g., esophagectomyl) </li></ul><ul><li>Recent ear nose and throat or gastric surgery </li></ul><ul><li>GI bleeding </li></ul><ul><li>Facial fractures </li></ul><ul><li>Severe coagulopathies </li></ul><ul><li>Nasal insertion is contraindicated in patients with head injury, epistaxis or sinusitis. </li></ul><ul><li>Check INR/PTT, hemoglobin and platelets prior to procedure to rule out coagulopathy. </li></ul>
  4. 4. RATIONALE FOR PROCEDURE #1 <ul><li>  1.  A feeding tube that sits in the small bowel results in improved tolerance of feeds and better absorption of nutrients. It may decrease the risk of aspiration in some patients. Bedside placement of small bowel feeding tubes (SBFT) may facilitate earlier feeding (1, 2, 3).Tube placement may induce bleeding in patients with coagulopathies or varicosities. Esophageal or gastric incisions may be perforated by tube advancement.All patients with head trauma should be presumed to have a possible basal skull fracture. CT and skull rays cannot rule basal skull fractures out. Anterior basal skull fractures may provide a communication between the nasal cavity and meninges that can increase the risk for meningitis. In severe facial and basal skull trauma, feeding tubes could be inadvertently advanced into the cranial cavity. Oral insertion is a safer route. </li></ul>
  5. 5.  2. Obtain Order <ul><li>Rule out contraindications to feeding tube insertion and check for allergies/sensitivity to erythromycin. Rule out significant QT prolongation (contraindication to erythromycin). </li></ul><ul><li>Obtain an order to: </li></ul><ul><li>Insert a small bowel feeding tube </li></ul><ul><li>Administer erythromycin 500 mg in 100 ml IV for feeding tube insertion (consider metoclopramide 10mg IV once if erythromycin is contraindicated). </li></ul><ul><li>Prediluted vials of erythromycin are available in the medication room fridge by room 3. </li></ul>
  6. 6. RATIONALE FOR PROCEDURE # 2 <ul><li>  2.  Erythromycin has been shown to stimulate gastric motility and facilitate gastric emptying (3). Metoclopramide has been reported to be a successful prokinetic agent, however, erythromycin is the first choice agent (4).               Contraindications to administering erythromycin include allergy or sensitivity. Caution should be used in patients with hepatic insufficiency.  Although erythromycin may cause prolongation of the QT interval, the risk for prolongation with a single dose is relatively low, unless significant preexisting prolongation is present. QT is prolonged is present if the distance from the beginning of the QRS to the end of the T wave is > 50% of the R to R interval. A chest xray will not reveal the tip of the feeding tube when placed in the small bowel and may or may not be appropriate for confirming stomach placement. </li></ul>
  7. 7.  3. Collect Supplies   <ul><li>Feeding tube </li></ul><ul><li>60cc syringe </li></ul><ul><li>Water for flushing feeding tube </li></ul><ul><li>Lubricant </li></ul><ul><li>Stethoscope </li></ul><ul><li>Tape for securing feeding tube </li></ul><ul><li>Gloves </li></ul>
  8. 8.  4. Prepare for Insertion <ul><li>Explain procedure to patient and family. </li></ul><ul><li>Wash hands and put on non-sterile gloves. </li></ul><ul><li>ALL feeding tube insertions require a minimum of 2 rays. </li></ul>
  9. 9. RATIONALE FOR PROCEDURE # 4 <ul><li>Preparation reduces anxiety and provide an opportunity to answer questions. </li></ul><ul><li>This is a clean procedure. </li></ul>
  10. 10.  5. Adjust Bed <ul><li>Patient should be in supine, upright position with HOB ~45 degrees as tolerated (unless contraindicated). </li></ul>
  11. 11. RATIONALE FOR PROCEDURE # 5 <ul><li>To facilitate the initial advancement into the stomach. </li></ul>
  12. 12. 6. Measure Placement <ul><li>Remove existing nasogastric or oral tube. </li></ul><ul><li>Measure the tip of the feeding tube from the end of the patient's nose to his/her ear, then down to the xiphoid process.  This usually measures approximately 35-40 cm.  </li></ul><ul><li>Make a note of the measurement. </li></ul>
  13. 13. RATIONALE FOR PROCEDURE # 6 <ul><li>This measurement will indicate when the feeding tube should have reached the stomach.If patient has a nasogastric or oral gastric tube in place, it should be removed prior to insertion of the feeding tube as it will interfere with the ability to 'corkscrew' the feeding tube into final position (5). </li></ul>
  14. 14. 7. Prepare Feeding Tube <ul><li>Dip the tip of the feeding tube in water. </li></ul><ul><li>Secure stylet tightly into the feeding tube. </li></ul><ul><li>Flush the tube with water. </li></ul><ul><li>Flush out water with air.  </li></ul><ul><li>Add extra lubricant to tip of tube. </li></ul>
  15. 15. RATIONALE FOR PROCEDURE # 7 <ul><li>The stylet provides tube stiffness to facilitate advancement. Flushing activates the lubricant for the tube. The water is flushed out to decrease the risk of inducing coughing, especially if the tube enters the airway. Extra lubricant facilitates easier insertion. </li></ul>
  16. 16. 8. Begin Insertion <ul><li>Connect the empty luer lock syringe to the guidewire end of the feeding tube. Be sure the feeding tube is firmly inserted and the connection is tight. Cap the medication port at the Y connection. </li></ul><ul><li>Utilize the oral route if nasal route is contraindicated (e.g., head injury, sinusitis) or if nasal resistance is met bilaterally. </li></ul>
  17. 17. <ul><li>If the patient has an NG/OG tube in place, identify whether gastric drainage will continue following small bowel placement of the feeding tube. If the NG/OG is to remain in place, review the X-ray to ensure the NG/OG tip is well away from the entry to the duodenum. If the NG/OG is low, withdraw until it is in the fundus. If the gastric drainage tube is not being removed, it should be clamped during insertion. </li></ul>
  18. 18. <ul><li>Gently insert the well lubricated tip of the feeding tube into one nare. If the tube cannot be advanced into the nasopharynx, gently manipulate the tip of the nose (upward and/or side to side) and reattempt. If resistance is met, attempt insertion into the other nare.  Do not force the tube. </li></ul>
  19. 19. <ul><li>Once the tube is in the pharynx, ask the patient (if able) to swallow and while slowly advancing the tube. If the patient is not intubated and has an intact gag reflex, you may provide a sip of water to aid in swallowing. If the patient continually coughs or his/her oxygen saturation drops during tube advancement, withdraw the tube and reattempt. </li></ul>
  20. 20. <ul><li>When the tube has been advanced to the ~30cm mark, try to aspirate. If you aspirate air, you are likely in the trachea (unless the connection is loose). If you feel a resistance when you draw back on the plunger and it then returns to its original position when released, you are likely in the esophagus (6) . </li></ul>
  21. 21. RATIONALE FOR PROCEDURE # 8 <ul><li>If the NG is at the pylorus, it may interfere with the placement of the feeding tube. </li></ul><ul><li>Swallowing during advancement of the feeding tube may facilitate movement into the esophagus. If the patient is intubated with an ETT or NTT, or is trached or extubated without a gag reflex, do not offer water to facilitate swallowing as it may induce coughing or cause aspiration. </li></ul><ul><li>Clamping of the OG/NG prevents loss of air during insufflation. </li></ul>
  22. 22. 9. Advance to Lower Esophagus <ul><li>Advance the tube to predetermined marking (35-40 cm). </li></ul>
  23. 23. RATIONALE FOR PROCEDURE # 9 <ul><li>Airway placement should be ruled out before the tube is advanced into the stomach or small bowel. This 2-step X-ray method protects the patient from harm should the tube be inadvertently placed into an airway. By limiting the intial advancement to 35-40 cm, the tube would remain in the airways, instead of perforating lung tissue. </li></ul>
  24. 24. 10. Confirm Placement in the GI tract <ul><li>Obtain a CHEST X-ray. Have X-ray assessed to RULE OUT airway placement. </li></ul><ul><li>DO NOT do an abdominal X-ray for the first view as the goal is to see the large airways. </li></ul>
  25. 25. RATIONALE FOR PROCEDURE # 10 <ul><li>Identify the carina on the X-ray. Follow the feeding tube. If the feeding tube follows the path of the trachea and continues into the right or left bronchus, airway placement has occurred and the tube should be pulled out and reinserted. GI placement can be identified if the tube has continued past the carina on chest X-ray (without following a bronchus), or if it is below the hemidiaphragm on an abdominal film. </li></ul>
  26. 26. <ul><li>pH has been reported to be a useful method for assessing tube placement, however, it can not be used to confirm placement. Tracheal secretions are alkaline (pH > 7), whereas, gastric secretions are acidic (pH < 5.5) even when an H2 blocker is used. The pH of small bowel fluid is alkaline (due to pancreatic bicarbonate). Although these guides have been suggested to assist with placement, they are not reliable. Gastric secretions may be alkaline if the patient has been swallowing tracheal secretions or if aspirate obtained from the stomach is closed to the duodenum and reflux has occurred. </li></ul>
  27. 27. 11. Position the Patient for Advancement of the Tube into the Small Bowel <ul><li>1. Following radiographic confirmation that the feeding tube has not migrated into an airway, advance the feeding tube an additional 20 cm to ensure it is in the stomach. Do not advanced beyond this point prior to administration of prokinetics, to avoid curling in the stomach. </li></ul><ul><li>2. Position the patient on the right side, with head of bed elevated. Maintain this position during administration of prokinetic agent until tube is advanced. </li></ul>
  28. 28. RATIONALE FOR PROCEDURE # 11 <ul><li>The stomach empties toward the right into the duodenum (5). </li></ul>
  29. 29. 12. Administer Prokinetic Agent <ul><li>Once airway placement has been ruled out, administer 500mg erythromycin in 100 ml IV, or maxeran 10 mg (if erythromycin is contraindicated) as per order. Whenever possible, erythromycin should be given centrally. Infuse over  30 minutes (60 minutes if peripheral administration; monitor peripheral intravenous sites closely).  Maxeran can be given by IV direct administration. </li></ul>
  30. 30. RATIONALE FOR PROCEDURE # 12 <ul><li>Peripheral administration can cause phlebitis. </li></ul><ul><li>Intravenous erythromycin enhances gastric motility, and improves the rate for successful placement of SBFT (3). </li></ul>
  31. 31. 13. Introduce Air Into the Stomach <ul><li>Within 30 minutes following completion of the erythromycin bolus, or 10 minutes following administration of IV maxeran, begin advancing the feeding tube into the small bowel (step 13 and 14). </li></ul><ul><li>If the patient has an NG tube connected to suction, clamp the NG. Inject ~ 300 - 500 cc of air into the feeding tube with a 60 cc syringe. </li></ul>
  32. 32. RATIONALE FOR PROCEDURE # 13 <ul><li>Air insufflation facilitates opening of the pyloric bulb and stimulates gastric motility (3,5). In adults, stomach volume can be anywhere from 1500 to 2000ml (5).  Injection of air may be contraindicated if patient had emesis or excessive nasogastric drainage prior to removal of NG.  Check with physician if uncertain. </li></ul><ul><li>If OG/NG remains in place, clamp before insufflation with air. </li></ul>
  33. 33. 14. Advance Tube into Small Bowel <ul><li>Begin advancing tube with a twisting, corkscrew-like motion in 10cm increments. If mild resistance is felt, continue advancing.  If strong resistance is felt, pull back 10cm and re-advance.  When you let go of the tube and it comes back out on its own, the tube was likely coiled upon itself.  Sudden decreases in resistance may also mean the tube is coiled (6,7). Continue advancing until only 10cm of the tube is visible. </li></ul>
  34. 34. RATIONALE FOR PROCEDURE # 14 <ul><li>The twisting motion turns the tip of the tube, helping it find the bulb of the pylorus (3,5). </li></ul>
  35. 35. 15. Auscultate <ul><li>While auscultating over the right upper quadrant, inject 20cc of air.  Do the same over the epigastric region and the left upper quadrant.  </li></ul><ul><li>Aspirate from a small bowel feeding tube is usually yellow in color and tests alkaline on a pH test strip. </li></ul><ul><li>Flush any aspirated fluid with saline to prevent the guidewire from adhering to the tube. </li></ul><ul><li>Note: Neither auscultation or aspirate characteristics provide confirmation of bowel placement. X-ray confirmation is required. </li></ul>
  36. 36. RATIONALE FOR PROCEDURE # 15 <ul><li>You will hear the air bolus loudest and with a high-pitch over the RUQ if the feeding tube has passed the pylorus.  Sounds to the LUQ will be very quiet (6,7). </li></ul>
  37. 37. 16. Secure the Tube <ul><li>Secure the feeding tube with tape, being careful not to put pressure on the patient's nares with the tube.  Leave guidewire pending X-ray confirmation. Identify the centimeter marking of the tube at the tip of the patient's nose.  Remove gloves and wash hands.  </li></ul>
  38. 38. RATIONALE FOR PROCEDURE # 16 <ul><li>Documentation on the Kardex provides a reference to identify if the tube has been pulled out of position.  </li></ul>
  39. 39. 17. Confirm Placement Prior to Feeding <ul><li>Obtain an ABDOMINAL X-ray for verification of feeding tube placement.  </li></ul><ul><li>If the feeding tube does not enter the small bowel, review with the resident whether gastric feeding would be appropriate. If small bowel placement is desired, the tube can be withdrawn (as long as the guidewire has not been removed) and reinserted. </li></ul><ul><li>Have resident verify X-ray placement and obtain an order &quot;may feed via feeding tube&quot;. If the feeding tube has been successfully placed in the small bowel, &quot;nasal small bowel placement&quot; should be identified in the order and documented in the AI record. </li></ul>
  40. 40. RATIONALE FOR PROCEDURE # 17 <ul><li>Xray confirmation is mandatory prior to administration of medications, flush solutions or feeding. No other method has conclusively confirmed placement. The risk of accidental feeding into a lung is associated with significant morbidity. </li></ul>
  41. 41. 18. Remove Guidewire <ul><li>Once placement has been verified by the physician, flush the guidewire with saline and gently remove guidewire. </li></ul>
  42. 42. RATIONALE FOR PROCEDURE # 18 <ul><li>Do not reinsert guidewire following removal, as the guidewire could puncture the feeding tube wall. </li></ul>
  43. 43. 19. Document Procedure <ul><li>Document procedure in the AI record. Record feeding tube size and length, final placement marking, technique used and patient response. Document teaching to patient or family. </li></ul><ul><li>Record feeding tube size, insertion date and centimeter marking of the tube (at the nare) on the Kardex.  </li></ul><ul><li>Note: If tube placement in the small bowel is confirmed, do not check for residuals from the feeding tube. Small bowel feeding may be initiated while gastric drainage is continued. </li></ul>
  44. 44. RATIONALE FOR PROCEDURE # 19 <ul><li>To communicate findings and meet documentation standards. </li></ul><ul><li>http://nursesinformations.blogspot.com </li></ul><ul><li>Source: http://www.lhsc.on.ca/critcare/icu/procedures/sbft.html </li></ul>

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