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Nasogastric intubation

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Nasogastric intubation

  1. 1. Nasogastric Intubation
  2. 2. GI Tract <ul><li>Oral cavity </li></ul><ul><li>Pharynx </li></ul><ul><li>Esophagus </li></ul><ul><li>Stomach </li></ul><ul><li>Small Intestine </li></ul><ul><li>Large Intestine </li></ul><ul><li>Accessory Structures </li></ul>
  3. 3. Gastrointestinal System <ul><li>Provides body with: </li></ul><ul><ul><li>Water </li></ul></ul><ul><ul><li>Electrolytes </li></ul></ul><ul><ul><li>Other nutrients used by cells </li></ul></ul>
  4. 4. Gastrointestinal System <ul><li>Function </li></ul><ul><ul><li>Breaks down ingested food </li></ul></ul><ul><ul><li>Propels food through the GI tract </li></ul></ul><ul><ul><li>Absorbs nutrients across wall of lumen of GI tract </li></ul></ul><ul><ul><li>Absorbs water and salts </li></ul></ul><ul><ul><li>Eliminates waste </li></ul></ul>
  5. 5. Oral Cavity <ul><li>Chemical Digestion </li></ul><ul><ul><li>Salivary glands produce saliva </li></ul></ul><ul><ul><li>Contains digestive enzyme </li></ul></ul><ul><ul><ul><li>Salivary amylase </li></ul></ul></ul><ul><ul><ul><li>Begins chemical breakdown of carbohydrates </li></ul></ul></ul>
  6. 6. Oral Cavity <ul><li>Mechanical Digestion </li></ul><ul><ul><li>Mastication facilitates swallowing and processing of food </li></ul></ul><ul><ul><li>Food swallowed by voluntary and involuntary mechanisms </li></ul></ul><ul><ul><li>Pharynx elevates to receive food from mouth </li></ul></ul>
  7. 7. Oral Cavity <ul><li>Mechanical digestion </li></ul><ul><ul><li>Esophageal sphincter relaxes, opening esophagus </li></ul></ul><ul><ul><li>Food is pushed into esophagus </li></ul></ul><ul><ul><li>Epiglottis closes airway to prevent aspiration </li></ul></ul>
  8. 10. The Gastrointestinal System <ul><li>The Oral Cavity </li></ul><ul><li>Chemical digestion </li></ul><ul><li>Mechanical digestion </li></ul><ul><li>Esophagus </li></ul><ul><li>Peristaltic waves </li></ul>
  9. 12. Esophagus <ul><li>Muscular canal (24 cm long) </li></ul><ul><li>Extends from pharynx to stomach </li></ul><ul><li>Begins below cricoid cartilage </li></ul><ul><li>Descends to sphincter of stomach </li></ul>
  10. 13. <ul><li>Esophagus: </li></ul><ul><li>Muscular canal </li></ul><ul><li>About 24 cm long </li></ul><ul><li>Extends from pharynx to stomach </li></ul>
  11. 14. Esophagus <ul><li>Composition </li></ul><ul><li>Lined with mucous membrane </li></ul><ul><li>Peristaltic waves push food into stomach </li></ul>
  12. 15. Stomach <ul><li>Structure </li></ul><ul><li>Layered muscular tube </li></ul><ul><li>Lined with mucous membranes </li></ul><ul><li>Contains gastric glands </li></ul>
  13. 16. Stomach <ul><li>Function </li></ul><ul><ul><li>Storage and mixing chamber </li></ul></ul><ul><ul><li>Secretes HCl, intrinsic factor, gastrin, pepsinogen </li></ul></ul><ul><ul><li>Produces chyme </li></ul></ul><ul><ul><li>Moves chyme into duodenum </li></ul></ul>
  14. 17. Small Intestine <ul><li>Begins at pyloric sphincter </li></ul><ul><li>Coils through abdominal cavity </li></ul><ul><li>Opens into large intestine </li></ul>
  15. 18. Small Intestine <ul><li>10 ft divided into 3 segments </li></ul><ul><ul><li>Duodenum </li></ul></ul><ul><ul><li>Jejunum </li></ul></ul><ul><ul><li>Ileum </li></ul></ul><ul><li>Mixing and propulsion of chyme </li></ul><ul><li>Absorption of fluid and nutrients </li></ul>
  16. 19. Small Intestine <ul><li>Peristaltic contractions </li></ul><ul><ul><li>Chyme moves through ileocecal valve </li></ul></ul><ul><li>Chyme enters cecum </li></ul><ul><li>Cecum distends </li></ul><ul><ul><li>Sphincter closes </li></ul></ul><ul><ul><li>Prevents contents from returning to ileum </li></ul></ul>
  17. 20. Large Intestine <ul><li>1.2m (5ft) long </li></ul><ul><li>6.2cm (2.2in) in diameter </li></ul><ul><li>Extends from ileum to anus </li></ul><ul><li>Attached to abdominal cavity by mesocolon </li></ul>
  18. 21. Large Intestine <ul><li>Divided into four principal regions </li></ul><ul><ul><li>Cecum </li></ul></ul><ul><ul><li>Colon </li></ul></ul><ul><ul><li>Rectum </li></ul></ul><ul><ul><li>Anal canal </li></ul></ul>
  19. 22. Large Intestine <ul><li>Absorbs water </li></ul><ul><li>Absorbs salts </li></ul><ul><li>Bacteria acts on undigested material </li></ul><ul><li>Converts chyme into feces </li></ul>
  20. 23. Liver <ul><li>Largest gland in body </li></ul><ul><li>Upper right quadrant </li></ul><ul><li>Vascular organ with 2 sources of blood supply </li></ul><ul><ul><li>Hepatic artery </li></ul></ul><ul><ul><li>Portal vein </li></ul></ul>Liver Portal vein Hepatic Artery
  21. 24. Liver <ul><li>Plays major role in: </li></ul><ul><li>Iron metabolism </li></ul><ul><li>Plasma-protein production </li></ul><ul><li>Detoxification </li></ul>
  22. 25. Liver <ul><li>Secretes bile </li></ul><ul><ul><li>600 – 1000 ml each day </li></ul></ul><ul><ul><li>Dilutes stomach acid (no digestive enzymes) </li></ul></ul><ul><ul><li>Emulsifies fats </li></ul></ul><ul><li>Bile salts </li></ul><ul><ul><li>Reabsorbed in ileum </li></ul></ul><ul><ul><li>Carried back to liver in blood </li></ul></ul><ul><ul><li>Also lost in feces </li></ul></ul>
  23. 26. Liver <ul><li>Metabolism </li></ul><ul><ul><li>Helps maintain blood glucose levels </li></ul></ul><ul><ul><li>Involved in fat and protein metabolism </li></ul></ul><ul><ul><li>Stores vitamins and minerals </li></ul></ul><ul><li>Toxin Breakdown </li></ul><ul><ul><li>Breaks down metabolism by-products </li></ul></ul><ul><ul><li>Can be toxic if accumulate in the body </li></ul></ul>
  24. 27. Liver <ul><li>Blood Protein Production </li></ul><ul><ul><li>Albumin </li></ul></ul><ul><ul><li>Fibrinogen </li></ul></ul><ul><ul><li>Globulin </li></ul></ul><ul><ul><li>Clotting factors </li></ul></ul>
  25. 28. Gallbladder <ul><li>Pear shaped sac </li></ul><ul><li>7-10 cm long (3-4”) </li></ul><ul><li>Located on posterior surface of liver </li></ul><ul><li>Hangs from anterior/inferior margin of liver </li></ul>
  26. 29. Gallbladder <ul><li>Secretes and stores bile produced by the liver </li></ul>
  27. 30. Pancreas <ul><li>Gland </li></ul><ul><li>12-15 cm (5-6 in) long </li></ul><ul><li>2.2 cm (1 in) thick </li></ul><ul><li>Posterior to the stomach </li></ul><ul><li>Connected to duodenum by 2 ducts </li></ul>
  28. 31. Pancreas <ul><li>Exocrine gland </li></ul><ul><ul><li>Secretes pancreatic juice </li></ul></ul><ul><li>Endocrine gland </li></ul><ul><ul><li>Secretes hormones (insulin) into blood </li></ul></ul><ul><ul><li>Cells need insulin to process glucose </li></ul></ul>
  29. 32. Pancreas <ul><li>Pancreatic juice </li></ul><ul><ul><li>Most important digestive juice </li></ul></ul><ul><ul><li>Contains digestive enzymes, sodium bicarbonate and alkaline substances </li></ul></ul><ul><ul><li>Neutralizes HCl in juices entering small intestine </li></ul></ul>
  30. 33. Nasogastric Intubation
  31. 34. NG Tube Indications <ul><li>Aspirate stomach contents </li></ul><ul><ul><li>Diagnostic or therapeutic </li></ul></ul><ul><li>Assessment of GI bleeding </li></ul><ul><li>Determine gastric acid content </li></ul>
  32. 35. NG Tube Indications <ul><li>Treat paralytic ileus </li></ul><ul><li>Treat intestinal obstruction </li></ul><ul><li>Recurrent vomiting likely </li></ul><ul><li>Trauma </li></ul><ul><li>Overdose </li></ul>
  33. 36. NG Tube Contraindications <ul><li>Esophageal strictures </li></ul><ul><li>Alkali ingestion, caustic ingestions, esophageal burns </li></ul><ul><li>Comatose patients </li></ul>
  34. 37. NG Tube Contraindications <ul><li>Trauma patients with: </li></ul><ul><ul><li>Cervical or intracranial bleeding </li></ul></ul><ul><ul><li>Increased intracranial pressure </li></ul></ul><ul><li>Recent surgery of the following types: </li></ul><ul><ul><li>Oropharyngeal </li></ul></ul><ul><ul><li>Nasal </li></ul></ul><ul><ul><li>Gastric </li></ul></ul>
  35. 38. Inserting NG Tube <ul><li>Explain procedure </li></ul><ul><li>Position patient </li></ul><ul><ul><li>High Fowler if alert </li></ul></ul><ul><ul><li>Drape </li></ul></ul><ul><ul><li>Emesis basin </li></ul></ul><ul><ul><li>Water and straw </li></ul></ul>
  36. 39. Inserting NG Tube <ul><li>Unconscious patient </li></ul><ul><ul><li>Left lateral position </li></ul></ul><ul><ul><li>Head turned to downward side </li></ul></ul><ul><ul><li>Gag and cough reflexes absent or suppressed </li></ul></ul><ul><ul><li>NG tube easily misplaced (lung) </li></ul></ul><ul><ul><li>Inability to swallow </li></ul></ul>
  37. 40. Inserting NG Tube <ul><li>Check nares for patency </li></ul><ul><li>Select appropriate tube size </li></ul><ul><li>Determine length of insertion </li></ul><ul><ul><li>Tip of nose, to ear, to xiphoid process </li></ul></ul><ul><ul><li>Mark tube </li></ul></ul>
  38. 41. Inserting NG Tube <ul><li>Lubricate tube </li></ul><ul><ul><li>Lubricant must be water-soluble </li></ul></ul><ul><ul><li>May use topical anesthetic if available (ie, lidocaine) </li></ul></ul><ul><li>Coil tube to shape it into curve </li></ul><ul><li>Have patient hold water and straw to mouth </li></ul>
  39. 42. Inserting NG Tube <ul><li>Insert tube </li></ul><ul><ul><li>Along floor of nose </li></ul></ul><ul><ul><li>Straight back </li></ul></ul><ul><ul><li>Advance until resistance felt (nasopharynx) </li></ul></ul>
  40. 43. Inserting NG Tube <ul><li>Ask patient to swallow sips of water and flex neck slightly. </li></ul><ul><li>As patient swallows, advance tube into and down esophagus. </li></ul>
  41. 44. Inserting NG Tube <ul><li>When tube is in the esophagus: </li></ul><ul><ul><li>Advance rapidly to the pre-marked distance </li></ul></ul><ul><li>Excessive choking, gagging, coughing, change in voice or condensation inside the tube indicates possibility of placement in trachea. The tube should be withdrawn. </li></ul>
  42. 45. Confirm NG Tube Placement <ul><li>X-ray </li></ul><ul><ul><li>Most reliable if tube is radiopaque </li></ul></ul><ul><ul><li>Requires order from physician </li></ul></ul><ul><li>Injecting air </li></ul><ul><ul><li>60 cc catheter syringe </li></ul></ul><ul><ul><li>Place stethoscope over LUQ of abdomen </li></ul></ul><ul><ul><li>Inject air into lumen of tube, NOT blue pigtail </li></ul></ul><ul><ul><li>Listen for “swoosh” sound </li></ul></ul>
  43. 46. Confirm NG Tube Placement <ul><li>Aspirate stomach contents </li></ul><ul><ul><li>60 cc catheter tip syringe </li></ul></ul><ul><ul><li>Pull back to check for gastric aspirate </li></ul></ul><ul><ul><li>Possibility for fluid to be from lungs or pleural space </li></ul></ul>
  44. 47. Confirm NG Tube Placement <ul><li>Test pH of gastric aspirate </li></ul><ul><ul><li>60 cc catheter-tip syringe and pH paper </li></ul></ul><ul><ul><li>pH < 4 = 95% chance that tip is in stomach </li></ul></ul><ul><ul><li>pH > 6 = may be in lung or pleural space; could be in stomach if patient takes antacids or some medications </li></ul></ul>
  45. 48. Confirm NG Tube Placement <ul><li>Non-radiopaque methods </li></ul><ul><ul><li>Possibility of error </li></ul></ul><ul><ul><li>Use more than one method </li></ul></ul><ul><ul><li>Passage into lungs frequent; especially in comatose or demented patients </li></ul></ul><ul><ul><li>Aspiration of gastric contents more reliable </li></ul></ul><ul><ul><ul><li>Especially if tested with pH paper </li></ul></ul></ul>
  46. 49. Securing the Tube <ul><li>Secure to patient’s nose </li></ul><ul><ul><li>Tape to nose and coil around tube </li></ul></ul><ul><ul><li>Avoid pressure to nares </li></ul></ul><ul><ul><li>Secure to patient’s clothing near shoulder area </li></ul></ul><ul><ul><li>Blue pigtail must be above level of patient’s stomach </li></ul></ul>
  47. 50. Complications <ul><li>Excessive coughing, motion, gagging may aggravate the following: </li></ul><ul><li>Neck injuries </li></ul><ul><ul><li>Increased risk for C-spine injuries </li></ul></ul><ul><li>Penetrating neck wounds </li></ul><ul><ul><li>May increase hemorrhage </li></ul></ul><ul><li>Tube misplacement </li></ul><ul><ul><li>Pulmonary </li></ul></ul><ul><ul><li>Intracranial </li></ul></ul>
  48. 51. Removing NG Tube <ul><li>Disconnect from drainage container and suction (if applicable) </li></ul><ul><li>Attach syringe-tip catheter to lumen of tube </li></ul><ul><li>Flush tube with 20cc of air </li></ul><ul><ul><li>Empties contents from tube to prevent aspiration into lungs </li></ul></ul>
  49. 52. Removing NG Tube <ul><li>Remove tape from patient’s nose </li></ul><ul><li>Unpin tube from gown </li></ul><ul><li>Have patient take deep breath and hold while tube is removed </li></ul><ul><li>Pull tube with quick and steady motion </li></ul><ul><li>Discard appropriately </li></ul><ul><li>Provide or instruct patient on oral and nasal care </li></ul>

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