Let’s Go Tubing! Let’s Go Tubing! Understanding GI and GU Understanding GI and GU

Tubes!Tubes!

Tracey Siegel MSN RN CNE Tracey Siegel MSN RN CNE CWOCNCWOCN

Objectives:Objectives:

1.1. Define various gastrointestinal and Define various gastrointestinal and genitourinary tubes used in nursing genitourinary tubes used in nursing practice.practice.

2.2. Discuss Evidence Based Care of GI Discuss Evidence Based Care of GI and GU tubes.and GU tubes.

Gastric TubesGastric TubesInsertion of a flexible tube into the Insertion of a flexible tube into the

stomach,stomach,

duodenum or jejunum for the purpose of:duodenum or jejunum for the purpose of:

• Decompressing the stomach Decompressing the stomach

• Removing gas and fluidRemoving gas and fluid

• Lavaging the stomach and remove toxinsLavaging the stomach and remove toxins

• DiagnosingDiagnosing

• Administering food, medicationsAdministering food, medications

• Treating obstructionsTreating obstructions

• Stopping bleedingStopping bleeding

Gastric TubesGastric TubesNasogastric tubesNasogastric tubes• Levin tubeLevin tube• Single lumenSingle lumen• Short term feedingShort term feeding or suctionor suction• Inserted nasally or Inserted nasally or

orallyorally

Salem sumpSalem sump• Dual lumen tubeDual lumen tube• Blue “pigtail” Blue “pigtail” • Designed for suctionDesigned for suction

Salem sump

Levin

Evidence Based Nursing Evidence Based Nursing CareCare• Check placement each Check placement each

shiftshift• Gold Standard is x-ray Gold Standard is x-ray

immediately after immediately after insertioninsertion

• Aspirate and measure Aspirate and measure pH (<4)pH (<4)

• Least accurate- Least accurate- auscultation methodauscultation method

• Measure length of Measure length of tubetube

• Excellent oral careExcellent oral care• No ice chips unless No ice chips unless

orderedordered

• Check nostrilCheck nostril• Assess vital signs Assess vital signs • Assess lung soundsAssess lung sounds• If suction is used- check If suction is used- check

drainage each shift- drainage each shift- expect some blood expect some blood tinged immediately tinged immediately after surgery and up to after surgery and up to 24 hours24 hours

• Gastric drainage is light Gastric drainage is light yellow to deep greenyellow to deep green

• Nurses cannot replace Nurses cannot replace NGT after gastrectomy!NGT after gastrectomy!

Evidence Based Nursing Evidence Based Nursing CareCareIf used for feeding orIf used for feeding or

Medication:Medication:placementplacement residualresidualaspirationaspirationCrush meds wellCrush meds wellDon’t crush enteric Don’t crush enteric

coated or long acting coated or long acting medicationsmedications

Give at least 15-30 ml Give at least 15-30 ml of water between each of water between each med!med!

Give extra water if Give extra water if allowedallowed

Keep HOB at 30 Keep HOB at 30 degreesdegrees

Gloves!!!

Gastric Tubes: small bore Gastric Tubes: small bore nasoduodenal or nasojejunal nasoduodenal or nasojejunal (Dobhoff)(Dobhoff)• Inserted by physician or specially trained Inserted by physician or specially trained

nursenurse

• Placement must be verified by x-ray Placement must be verified by x-ray (weighted end)(weighted end)

• Narrow lumen but less risk for aspiration Narrow lumen but less risk for aspiration for patients needing long term feedingfor patients needing long term feeding

• Best to use only liquid medications but no Best to use only liquid medications but no always possible so always possible so best practicebest practice calls for calls for pharmacy to pulverize pills and place in pharmacy to pulverize pills and place in liquidliquid

Read More About ItRead More About It

•http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2006/Dec3(4)/Pages/23.aspx#bm2

•http://www.nursingcenter.com/prodev/ce_article.asp?tid=771094

Percutaneous endoscopic Percutaneous endoscopic tubes (PEGS or PEJS)tubes (PEGS or PEJS)

IndicationsIndications

• Long term nutritional Long term nutritional supplementationsupplementation

Nursing ManagementNursing ManagementResidualResidualPlacementPlacementLength of tubeLength of tube Don’t put dressings Don’t put dressings

under the bumper- can under the bumper- can alter position of tubealter position of tube

Stabilize the tube!Stabilize the tube!

Nasointestinal Tubes: Miller Nasointestinal Tubes: Miller Abbot or CantorAbbot or Cantor• Small bowel or large bowel Small bowel or large bowel

obstructionsobstructions• Inserted by physicianInserted by physician• Patient should be Patient should be

repositioned or allowed to repositioned or allowed to walk to promote tube walk to promote tube insertion and peristalsisinsertion and peristalsis

• Not taped until in place and Not taped until in place and verified by x-rayverified by x-ray

• No placement check No placement check neededneeded

• Attached to suctionAttached to suction• Short termShort term• Mercury or other weight on Mercury or other weight on

bottom of tubebottom of tubeRarely used- still see NCLEX questions

Sengtaken Blakemore Tube or Sengtaken Blakemore Tube or Minnesota tubeMinnesota tube

EsophagealEsophagealTamponade or Tamponade or compression ofcompression ofesophageal varices toesophageal varices toControl hemorrhageControl hemorrhage

Rarely used- no Rarely used- no evidence ofevidence of

effectiveness however effectiveness however stillstill

may be asked on may be asked on NCLEX!!!!NCLEX!!!!

Care of patient with Blakemore Care of patient with Blakemore tubetube• Tube presses on esophagus to stop Tube presses on esophagus to stop

bleeding thereforebleeding therefore AIRWAYAIRWAY is primary is primary• Elevate HOBElevate HOB• Keep Keep scissorsscissors at bedside in case tube at bedside in case tube

needs to be deflated (respiratory needs to be deflated (respiratory distress)distress)

• Monitor for bleeding, esophageal rupture Monitor for bleeding, esophageal rupture (severe pain, shock- medical emergency)(severe pain, shock- medical emergency)

• Placement is verified by x rayPlacement is verified by x ray• Patient will be in critical care!Patient will be in critical care!

T Tube: for bile drainageT Tube: for bile drainage

Care of patient with T-TubeCare of patient with T-Tube

• Placed in common bile duct during GB Placed in common bile duct during GB surgery or in radiologysurgery or in radiology

• Attached to a drainage bag but not Attached to a drainage bag but not sutured in (verify each shift)sutured in (verify each shift)

• Bile is caustic to skin (dressing around) Bile is caustic to skin (dressing around) Make sure it doesn’t get kinkedMake sure it doesn’t get kinked

• Normal to drain 700-1200ml/dayNormal to drain 700-1200ml/day

• Patient may be discharged with- can stay Patient may be discharged with- can stay in up to 6 weeks in up to 6 weeks

Urinary CathetersUrinary Catheters

Best Practices and Evidence Based Best Practices and Evidence Based Care of Indwelling Urinary Care of Indwelling Urinary

CathetersCatheters• Catheterize only when absolutely neededCatheterize only when absolutely needed• Educate personnel on correct catheter insertion Educate personnel on correct catheter insertion

techniquetechnique• Hand WashingHand Washing• Secure the catheterSecure the catheter• Maintain unobstructed urine flowMaintain unobstructed urine flow• No irrigations unless absolutely necessary (after GU No irrigations unless absolutely necessary (after GU

or prostate surgery OK)or prostate surgery OK)• Don’t routinely changeDon’t routinely change• No special care of meatus needed (soap and water No special care of meatus needed (soap and water

OK)OK)• Keep drainage bag off floor and below level of Keep drainage bag off floor and below level of

bladderbladder

Surgical DrainsSurgical Drains

• HemovacHemovac

• Jackson PrattJackson Pratt

• Penrose DrainPenrose Drain

Immediately following a gastrectomy, Immediately following a gastrectomy, a nurse in the recovery room notes a nurse in the recovery room notes blood clots in the patient’s nasogastric blood clots in the patient’s nasogastric tube drainage. What should the nurse tube drainage. What should the nurse do?do?

1.1. Clamp the tubeClamp the tube

2.2. Continue to monitor Continue to monitor

3.3. Instill iced saline into the tubeInstill iced saline into the tube

4.4. Call the surgeon immediatelyCall the surgeon immediately

After abdominal surgery, the client returns After abdominal surgery, the client returns to the nursing unit with a nasogastric tube to the nursing unit with a nasogastric tube connected to low intermittent suction. The connected to low intermittent suction. The physician has ordered an antiemetic every 6 physician has ordered an antiemetic every 6 hours as needed. The client vomits. What is hours as needed. The client vomits. What is the first action by the nurse?the first action by the nurse?

1.1. Check the placement of the Check the placement of the nasogastric tube.nasogastric tube.

2.2. Administer the ordered antiemetic.Administer the ordered antiemetic.

3.3. Irrigate the tube with normal Irrigate the tube with normal saline.saline.

4.4. Notify the physician. Notify the physician.

A nurse instructs the client who A nurse instructs the client who has a nasogastric tube (N/G) after has a nasogastric tube (N/G) after colon resection that the tube will colon resection that the tube will be removed after the client:be removed after the client:

1.1. tolerates fluids.tolerates fluids.

2.2. has a bowel movement.has a bowel movement.

3.3. has no nausea for two days. has no nausea for two days.

4.4. passes flatus.passes flatus.

The nurse has inserted a nasogastric The nurse has inserted a nasogastric tube. How should placement be tube. How should placement be assessed?assessed?

1.1. Place the end of the tube in a glass Place the end of the tube in a glass of water and check for bubbles.of water and check for bubbles.

2.2. Aspirate contents and check with Aspirate contents and check with litmus paper.litmus paper.

3.3. Inject air and listen over the Inject air and listen over the stomach for gurgling.stomach for gurgling.

4.4. Irrigate sterile water and listen over Irrigate sterile water and listen over the stomach for gurgling.the stomach for gurgling.

The nurse is caring for a patient The nurse is caring for a patient with a T-Tube. The tube has with a T-Tube. The tube has drained 300 ml over the past 24 drained 300 ml over the past 24 hours. What should the nurse do?hours. What should the nurse do?

1.1. Clamp the tube and call the physician.Clamp the tube and call the physician.

2.2. Attach the tube to low intermittent Attach the tube to low intermittent suction.suction.

3.3. Irrigate the tube with 50 ml of normal Irrigate the tube with 50 ml of normal saline.saline.

4.4. Empty the drainage bag and document Empty the drainage bag and document the output the output

A client is being discharged on A client is being discharged on bolus gastrostomy tube feedings. bolus gastrostomy tube feedings. The nurse would be concerned if The nurse would be concerned if which of the following procedures which of the following procedures by the client was observed?by the client was observed?

1.1. Checking the residual prior to feeding.Checking the residual prior to feeding.2.2. Instilling the feeding at room Instilling the feeding at room

temperature.temperature.3.3. Lying down and resting after the Lying down and resting after the

feeding.feeding.4.4. Washing around the gastrostomy with Washing around the gastrostomy with

soap and water.soap and water.

A nurse has an order to remove an A nurse has an order to remove an indwelling urinary catheter (foley). indwelling urinary catheter (foley). What is the most important nursing What is the most important nursing action prior to removal?action prior to removal?

1.1.Donning sterile gloves.Donning sterile gloves.

2.2.Deflating the catheter’s balloon.Deflating the catheter’s balloon.

3.3.Cleaning the meatus with soap and Cleaning the meatus with soap and water.water.

4.4.Asking the client to “take a deep Asking the client to “take a deep breath”.breath”.

Questions???Questions???TSiegel@middlesexcc.edu