2. TOPICS:
• Gastric Analysis, Gastric Acid Stimulation Test, pH monitoring
• Laparotomy (Peritoneoscopy)
• Levin Tube
• Gastric (Salem) Sump
• Nasogastric and Nasoenteric Tube for administration of tube
feedings, fluids, and medications
3. Analysis of the gastric
juice yields information
about the secretory
activity of the gastric
mucosa and the presence
or degree of gastric
retention in patients
thought to have pyloric or
duodenal obstruction.
GASTRIC ANALYSIS
5. Before gastric analysis the patient must be :
• NPO for 8 to 12 hours
• Smoking is not allowed on the morning of the test because it
increases gastric secretion
• Any medications that affect gastric secretions are withheld
for 24 to 48 hours before the test (anticholinergics,
antacids, H2 antagonists, proton pump inhibitors, PGE2
agonists)
GASTRIC ANALYSIS
6. PROCEDURE
• A small NGT with a catheter tip marked at
various points is inserted through the nose.
• When the tube is at a point slightly less
than 50 cm (21 inches), it should be within
the stomach, lying along the greater
curvature.
• Once in place, the tube is secured to the
patient's cheek and the patient is placed in
a semi-reclining position.
• The entire stomach contents are aspirated
by gentle suction into a syringe, and gastric
samples are collected every 15 mins for 1
hour.
GASTRIC ANALYSIS
7. • Measures the amount of
gastric acid made by the
stomach.
• Patient receives histamine or
pentagastrin injection
• A tube is put through the
nose or throat into the
stomach and samples are
taken from the stomach and
sent to a laboratory for
testing.
GASTRIC ACID STIMULATION
TEST
8. • Inform patient that injection
may produce a flushed
feeling.
• Monitor blood pressure and
pulse frequently to detect
hypotension.
• Gastric specimens are
collected after the injection
every 15 mins for 1 hr and
are labeled to indicate the
time of the specimen
collection after histamine
injection.
GASTRIC ACID STIMULATION
TEST
9. The esophageal pH test is an
outpatient procedure
performed to measure the pH
or amount of acid that flows
into the esophagus from the
stomach during a 24-hour
period.
Normal = 7.0
Ph monitoring
10. Esophageal reflux of
gastric acid may be
diagnosed and evaluated by
ambulatory pH monitoring.
The patient is NPO for 6
hours before the test.
Ph monitoring
11. A sensor that measures pH is
inserted and positioned via
endoscopy. The sensor is then
connected to an external
recording device and is worn
for 24 hours while the
patient continues usual daily
activities. The result is a
computer analysis and graphic
display of the results.
Ph monitoring
12. • It measures the amount of acidity (pH) in the
esophagus.
• It offers the advantage of pH monitoring of the
esophagus without the transnasal catheter.
Bravo Ph monitoring
13. The clinician, by means of endoscopy, attaches a capsule (approximately
the size of a gel cap) to the patient's esophageal wall.
Data are collected for up to 96 hours and then downloaded and
analyzed.
The capsule spontaneously detaches from the esophagus in 7 to 10 days
and then is passed through the patient's digestive system.
The accuracy of this method of pH testing is greater than methods in
which the catheter is used because the patient can eat normally and
continue typical activities during the testing.
Bravo Ph monitoring
15. • direct visualization of the organs
and structures within the
abdomen, permitting
visualization and identification
of any growths, anomalies and
inflammatory processes.
• Biopsy samples can be taken
from the structures and organs
as necessary.
16. • used to evaluate
peritoneal disease,
chronic abdominal
pain, abdominal
masses, and
gallbladder and liver
disease.
17. • Requires general anesthesia and sometimes
requires that the stomach and bowel be
decompressed.
• Insufflated with gas to create a working space for
visualization.
• After visualization of the problem, excision can
then be performed at the same time, if
appropriate.
18. A one-lumen
nasogastric/orogastric tube.
It is usually made of plastic
with several
drainage holes near the
gastric end of the tube. This
nasogastric tube is useful in
instilling material
into the stomach
LEVIN TUBE
20. LARGE LUMEN - allows for
easy suction of gastric
contents, decompression,
irrigation and medication
delivery.
SALEM SUMP
21. SMALLER VENT LUMEN - allows
for atmospheric air to be drawn
into the tube and equalizes the
vacuum pressure in the
stomach once the contents
have been emptied. This
prevents the suction eyelets
from adhering to and
damaging the stomach lining.
SALEM SUMP
23. Feeding via the enteric route infers that
the intestines are receiving nutrients.
Thus, delivering enteral nutrition refers
to infusing nutritional formula feedings
through a tube directly into the GI tract.
24. ADMINISTERING TUBE FEEDINGS
● Tube feedings are given to meet nutritional requirements when:
oral intake is inadequate or not possible and the GI tract is functional.
● The feedings are delivered to:
stomach, duodenum, or proximal jejunum and help preserve GI
integrity by preserving normal intestinal and hepatic metabolism.
25. CONDITIONS THAT MAY REQUIRE ENTERAL THERAPY
Alcoholism, chronic depression,
anorexia nervosa
Hypermetabolic conditions
Cancer therapy
Coma, semi-unconsciousness Maxillofacial or cervical surgery
Convalescent care Oropharyngeal or esophageal
paralysis
Gastrointestinal problems Preoperative bowel preparation
26. FORMULAS
The choice of formula to be delivered by tube feeding is influenced by:
● Status of the GI tract
● Nutritional needs of the patient
Formula characteristics:
● Chemical composition of nutrient source (CHONS, CHO, FAT)
● Caloric density
● Osmolality
● Fiber content
● Vitamins
● Minerals
● Electrolytes
● cost
27. FORMULAS
POLYMERIC FORMULAS
- Most common
- Composed of CHONS (10-15%), CHO (50-60%), FATS (30-35%)
- Undigested and require normal digestive function
SPECIALTY FORMULAS
- Prescribed to treat disease-specific disorders, organ-specific disorders, sepsis,
trauma, or to support wound-healing or immune-modulation
28. CHEMICALLY-DEFINED OR PREDIGESTED FORMULAS
- Contain easier-to-absorb nutrients
MODULAR PRODUCTS
- Contain only one major nutrient, such as protein
- Used to enhance commercially prepared products
FIBER
- Either premixed in or added to formulas, helps bulk the stool to decrease the
occurrence of both diarrhea and constipation
29. ADMINISTRATION METHODS
Depends on the:
- Location of the tube in the GI tract
- Patient tolerance
- Convenience
- Cost
1. BOLUS FEEDING
- Requires dividing the total daily feeding volume into 4 to 6 feeds throughout
the day
- Boluses can be given into a stomach through a large syringe (50mL) via gravity
30. 1. BOLUS FEEDING
- Typical volume is 200 to 400mL of feeding over a 15 to 60-minute period
- Can be delivered as quickly as the pt can tolerate them, but are initiated slowly,
increasing the rate as tolerated
- The amount of flow rate is determined by the pt
response:
If the pt feels full, it may be desirable to slow the
delivery time or give smaller volumes more frequently
31. 2. INTERMITTENT GRAVITY DRIP FEEDING
METHOD
- Requires administering feedings over
30mins or longer at designated intervals
by a reservoir enteral bag and tubing,
with the flow rate regulated by a roller
clamp or automated pump.
32. 3. CONTINUOUS FEEDING
- Deliver of feedings incrementally by a slow
infusion over long periods.
- Slow drip feedings are recommended for pt who
are critically ill; at high risk for aspiration; at risk
for intolerance; for small bowel feedings
33. 3. CYCLIC FEEDING
- Alternative to the continuous infusion
- Infused feeding is given by an enteral feeding pump
over 8 to 18 hrs
- Feedings may be infused at night to avoid interrupting
pt lifestyle
- Appropriate for pt who are being weaned from tube
feedings to an oral diet; who cannot eat enough and
need supplements; pt at home who need daytime hrs
free from the pump
34. MAINTAINING FEEDING
EQUIPMENT
AND NUTRITIONAL BALANCE
Factors to consider when tube
feedings are given:
• Temperature and volume
of feeding
• Flow rate
• Patient’s total fluid intake
35. MAINTAINING FEEDING
EQUIPMENT
AND NUTRITIONAL BALANCE
Measuring gastric residual volume (GVR)
• Done by removing gastric contents with a large syringe at routine
intervals.
• Hold the feeding for 2 hrs if the GVR is greater than 500mL
Maintaining tube function
• To ensure patency and to decrease the chance of bacterial growth, sludge
build-up, or occlusion of the tube, at least 30mL of water flush is
recommended in adults receiving tube feedings in each of the ff
instances:
36. MAINTAINING FEEDING
EQUIPMENT
AND NUTRITIONAL BALANCE
1. Before and after intermittent tube feeding
2. Before and after medication administration
3. After checking for gastric residuals (if required by policy) and gastric pH
4. Every 4 hrs with continuous feedings
5. When the tube feeding is discontinued or interrupted for any reason
Water used to flush must be recorded as fluid intake.
37. MAINTAINING FEEDING
EQUIPMENT
AND NUTRITIONAL BALANCE
Distribution (i.e. tap) or drinking (i.e. distribution and bottled) water can be
used, but the likelihood of contamination with pathogens must be
considered.
Purified (contaminant free; distillation or ultrafiltration) or sterile water
should be used for medication preparation.
Sterile water – immunocompromised pt and for reconstitution of powdered
formula
38. Providing medications by tube
The feeding is paused, and the tube is flushed with at least 15mL of water
before and at least 15mL of water after medication administration (30mL total).
Considerations:
• Preparation
• Absorption
• Patient’s fluid volume status
39. Maintaining delivery systems
1. OPEN SYSTEM
- Packaged as a liquid or a pwder to be mixed with water that is either poured
into a feeding container or given by a large syringe.
- The feeding container and the tubing used should be changed every 24 hrs.
- Can be used for:
bolus feedings
intermittent feedings
continuous feedings
- Can be delivered by:
Push
Syringe
Pump
40. Maintaining delivery systems
1. OPEN SYSTEM
- The formula hang time in the bag at room temp should never exceed what
the formula manufacturer recommends, usually no more than 4-8 hrs.
2. CLOSED SYSTEM
- Uses a prefilled, sterile container of about 1L of formula that is spiked with
enteral tubing.
- Allows a typical hang time of 24 hrs at room temp.
- Must always use a pump to control formula rate in order to avoid dispensing
a large formula volume in a short period of time.
- Lower risk of infection
41. Maintaining normal bowel
elimination pattern
Dumping syndrome
• Formula is infused into the small intestine quickly or formula bypasses the
stomach too readily into the small intestines and causes expansion of the
intestinal wall.
• Bloating, cramping, diarrhea, dizziness, diaphoresis, weakness
42. PREVENTING DUMPING
SYNDROME
Slow the formula instillation rate to provide time for CHO and electrolytes to
be diluted.
Administer feedings at room temp, because temp extremes stimulate
peristalsis.
Administer feeding by continuous drip (if tolerated) rather than by bolus, to
prevent sudden distention of the intestine.
Advise patient to remain in semi-Fowler position for 1 hr after feeding.
Instill the minimal amount of water needed to flush the tubing before and
after feeding.
43. Maintaining adequate hydration
Water flushes are given every 4 hrs and after feedings to prevent hypertonic
dehydration.
The feeding may be initially given as a continuous drip in order to help the
patient develop tolerance.
Key nursing interventions:
• Observing for signs of dehydration (dry mucous membranes, thirst,
decreased urine output)
• Administering water routinely
• Monitoring intake and output, residual volume, and fluid balance
44. Promoting coping ability
Psychosocial goal:
• Support and encourage the patient to accept physical changes and to
convey hope that daily progressive improvement is possible.
Encourage self-care
Identify indicators of progress
Daily weight trends
Electrolyte balance
Absence of nausea and diarrhea
Improvement in plasma proteins
45. Educating patients about self-care
The nurse educates the patient and caregiver while administering the feedings
so that they can observe the mechanics and participate in the procedure, ask
questions, and express any concerns.
Before discharge, the nurse provides info about:
Equipment needed
Formula purchase and storage
Administration of the feedings and water flushes
Available printed info about the equipment, formula, and procedure is
reviewed.
46. Educating patients about self-care
Patients who may require long-term tube feedings:
• Had recent surgery
• Dysphagia due to a neuromuscular disease
• Head and neck cancer
• Radiation or other types of trauma to the throat
• Obstruction of the upper GI tract
• GI cancer
• GI disease
• Decreased level of consciousness
51. Alternative resources
Here’s an assortment of alternative resources whose style fits the one of
this template:
Vectors
● Educational science concept
