Fundamental part II

Nutrition and Metabolism

By: Mamo .S (BSc in AHN )
04/29/2023 MS 1
 Objectives

At the end of this lesson the students will be

able to:-
 Nutrition
 Define the term nasogastric tube
 Describe Enteral and parenteral nutrition
 List the purpose of NG tube insertion
 Discuss how to perform NG tube insertion

04/29/2023 MS 2
 Nutrition
• Nutrition is a basic component of health and it is
essential for normal growth and development,
tissue maintenance and repair, cellular
metabolism, and organ function.
• They are biochemical substances obtained from
ingested food and fluid.
• Carbohydrates, proteins and fats are nutrients
that supply the body with energy.
• Vitamins, minerals, trace elements and water
are not sources of energy but are important in
regulating body process.
3
 Nutrients are categorized in to six
categories:
1. Carbohydrates
2. Fats
macronutrients
3. Proteins
4. Vitamins
5. Minerals
6. Water micronutrients
• Subgroup of minerals is called “trace elements”

4
 Cont’…
• The digestive system consists of the organs of the
GI tract(mouth, pharynx, esophagus, stomach,
small intestine and large intestine) and
• accessory organs ((tongue, salivary glands, teeth,
liver pancreas and gall bladder).
• The digestive system is responsible for converting
food into substances that the body’s cells can
absorb and use.
• Conversion of food involves the process of
digestion, absorption, metabolism and excretion.

5
 Cont’…
• Digestion: is the process by which foods are
broken down for the body to use in growth, dep't,
healing and prevention of d/se.
• It involves mechanical and chemical process.
• Absorption: is the process by which digested
proteins, fats, carbohydrates, vitamins, minerals
and water are actively and passively transported
through the intestinal mucosa in to the blood or
lymphatic circulation.

6
 Cont’…
• Metabolism: after digestion and absorption of
ingested food, they are ready to be metabolized.
• Metabolism is a complex chemical process that
occurs in the cell to allow for energy use and for
cellular growth and repair.
• It involves catabolism and anabolism
• Excretion: excretory organs(kidneys, sweet
glands, skin, lungs, and intestines) remove waste
products from the body.

7
 Cont’ ….
• Anabolic process build up substances and body
tissue,
• Catabolic process break down substances or
body stores.
• Energy obtained from food is measured in
colories /kilocalories (Cal/kcal)

8
 Nasogastric Tube
• There are two routes for delivery of nutrition
support (NS) in adult clients:
• Enteral nutrition
– Includes both the ingestion of food orally and the
delivery of nutrients through a gastrointestinal
tube.
• Parenteral nutrition
– Refers to nutrients entering the blood directly and
parenteral administration of nutrients and foods.

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 Nasogastric Tube

• NG tube is a thin, flexible plastic

tube that can be inserted into a
client’s nose and advanced into the
stomach.

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 Nasogastric Tube
• NG tube

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 Parenteral Nutrition

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 Parenteral nutrition
 Def: a method of feeding patients by infusing a
mixture of all necessary nutrients into the
circulatory system, thus bypassing the GIT.
 It is the infusion of a solution directly into a vein to
meet the client’s daily nutritional requirements.
 Formerly called hyperalimentation,
 it is frequently referred to as total parenteral
nutrition (TPN)

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 Parenteral nutrition
• It is the intravenous infusion of a solution
containing dextrose, amino acids, fats, essential
fatty acids, vitamins, and minerals
• The type of device used for the PN therapy is
determined by the duration of the therapy and the
osmolality of the solution.
• Peripheral parenteral nutrition (PPN) is used for
short-term treatment to deliver isotonic or mildly
hypertonic solutions into a peripheral vein;

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 Parenteral nutrition
 the volume is usually limited to between 2,000 and
3,000 ml/day, providing a caloric value of about
2,000 kcal/day.
 Central parenteral nutrition (CPN) is used for long
term therapy to infuse highly hypertonic solutions
directly into the superior vena cava.
 The delivery of highly hypertonic solutions into
peripheral veins can cause sclerosis, phlebitis, or
swelling;

04/29/2023 15
Purpose:-
Provide parenteral nutritional support to:
1. Malnourished clients
2. Clients who are NPO for extended periods of time
3. Clients requiring bypass of the GI tract for
prolonged period
4. Clients who have excess metabolic needs due to
trauma , cancer, or hyper metabolic state

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 Indication short /long
Short-Term (up to 2 weeks)
1. Preoperative for severely depleted clients
2. Postoperative for abdominal surgery clients who
have been NPO for several days because of an ileus
3. Inflamed or ulcerated bowel needing 1 or more
weeks of rest: (acute exacerbations of Crohn’s
disease and colitis, radiation enteritis, acute or
necrotizing pancreatitis, or an enter cutaneous or
high-output fistula)

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 Indication Short-Term
4. Congenital anomalies before surgical repair:
intestinal obstruction, tracheo-esophageal fistula,
mid gut mal rotation, volvulus, and omphalocele

5. Short-bowel syndrome: small-bowel resection of

75% or more to control diarrhea and prevent
dehydration and malnutrition

6. Cancer clients receiving chemotherapy or

radiation therapy

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Long-Term (greater than 2 weeks)
1. Hyperemesis gravidarum
2. Low-birth weight neonates
3. Failure to growth or development
4. Hard to control diarrhea
5. Severely burned clients

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• The gut should always be the preferred route for
nutrient administration.

• Therefore, parenteral nutrition is indicated

generally when there is severe gastro-
intestinal dysfunction (patients who cannot take
sufficient food or feeding formulas by the enteral
route) .

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 Categories of PN
• If enteral feeding is completely stopped or
ineffective, Total Parenteral Nutrition is used
(TPN).

• If enteral feeding is just “not enough” ,

supplementation with Partial Parenteral Nutrition
(PPN) is indicated.

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 Nutrition support in adult

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 Enteral versus parenteral nutrition
• As far as gastrointestinal failure is concerned,
long term parenteral nutrition is a life-saving
procedure.
• Enteral nutrition has the advantage over
parenteral nutrition of lower % of infectious
complications.
• Parenteral nutrition has been shown to lead to
changes in intestinal morphology and function
and an increase in permeability (with higher % of
bacterial translocation)
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 Nutritional Requirements
• Energy: Glucose
Lipid
• Amino acids (Nitrogen)
• Water and electrolytes
• Vitamins
• Trace elements

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 Application:
Venous access
PPN: a peripheral line can be enough.
TPN: Central venous access is fundamental
• Catheter can be placed via the subclavian vein, the
jugular vein (less desirable because of the high rate
of associated infection), or a long catheter placed in
an arm vein and threaded into the central venous
system (a peripherally inserted central catheter line)
• Once the correct position of the catheter has been
established (usually by X ray), the infusion can
begin.
25
 Application:
Initiation of Therapy
• TPN infusion is usually initiated at a rate of 25 to 50 mL/h.
This rate is then increased by 25 mL/h until the
predetermined final rate is achieved.
Administration
• To ensure that the solution is administered at a continuous
rate, an infusion pump is utilized to administer the solution.
• In hospitalized patients, infusion usually occurs over 22-24
h/day.
• In ambulatory home patients, administration usually occurs
overnight (12-16 h).

26
Precaution
1. Verify placement of feeding line prior to
administration of liquids.
2. Administer nutrients in accordance with the
prescribed time interval.
3. Keep PN refrigerated; remove from refrigerator
30 minutes prior to administration.
4. Change PN tubing every 24 hours.

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 Equipment

• TPN solution
• IV controllers or pumps
• Appropriate IV tubing with filter
• IV pole
• TPN dressing kit
• Sterile Gloves and mask
• Blood glucose monitoring equipment

04/29/2023 28
Procedure
1. Schedule and assist client with chest x-ray after
central catheter insertion
2. Confirm correct solution is running at order rate.
3. Check solutions expiration date .
4. Use infusion controller to monitor and regulate flow
rate
5. Inspect tubing and catheter connection for leaks or
kinks. Tape all connections. Change tubing every 24
hours accordingly to agency policy
6. Inspect insertion site for infiltration, thrombophelibits
or drainage. If present, notify physician. he may
order removal of the catheter and culture of the
catheter tip
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 Cont’d…

7. Monitor vital signs , including temperature every

4 hours
8. Assess for symptoms of air embolism (i.e.,
decrease level of consciousness, tachycardia,
dyspnoea, anxiety, ”feeling of impending doom”,
chest pain, cyanosis, hypotension)
• Note : if suspected ,lay clients on left side with
head in trendelenburg position.
9. Use the TPN line only for administration of
TPN and lipids. Don’t use the line for any
other reason

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 Cont’d…

10. Perform test for glucose every 6 hours. Notify the

physician if abnormal
11. Monitor laboratory test of electrolyte, BUN,
glucose as order and report abnormal finding
12. Maintain accurate record of intake and output to
monitor fluid balance
13. Weigh client daily and record
14. Inspect dressing once shift for drainage and
intactness. Change whenever loose or moist and at
least every 48 hours.
15. Wash hands and document procedure in the
client’s medical record
04/29/2023 31
 Complications of TPN
• Sepsis
• Pneumothorax
• Air embolism
• Clotted catheter line
• Catheter displacement
• Fluid overload
• Hyperglycemia
• Rebound Hypoglycemia

04/29/2023 32
 Enteral feeding
Gastrostomy/Jejunostomy Feedings
• A gastrostomy feeding is the installation of liquid
nourishment through a tube that enters a surgical
opening (called a gastrostomy) through the
abdominal wall in to the stomach.
• A jejunostomy feeding is the installation of liquid
nourishment through a tube that enters a surgical
opening (a jejunostomy) through the abdominal wall
in to the jejunum.
• These feedings are usually temporary measures.
When there is an obstruction the esophagus, they
may be come permanent, for example, after
removal of the esophagus
04/29/2023 33
 Gastrostomy feeding
• Gastrostomy is an operation performed to create
an opening in to the stomach for the purpose of
administering food and medications.
• For insertion of the gastrostomy tube requires
either upper abdominal midline incision or a left
upper quadrant transverse incision.
Purpose
 For long term use and total feeding
supplementation.
 For patients who cannot tolerate nasogastric or
nasoentric tube.

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 Gastrostomy Feeding
• Gastrostomy feeding tube

04/29/2023 MS 35
 Nasogastric Tube
• NG

04/29/2023 MS 36
 Gastrostomy Feeding
• Gastrostomy

04/29/2023 MS 37
 Gastrostomy Feeding
• .

04/29/2023 MS 38
 Bolus gastrostomy feeding by gravity. (A) Feeding is instilled at an angle so that air
does not enter the stomach

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Equipments
• Gastrostomy tube
• 50 ml syringe
• Funnel
• Clamper
• Measuring jag
• Sterile gauze
• Adhesive tape
• Chart

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Procedure of gastrostomy feeding
1. Explain the procedure to the patient
2. Wash hand
3. Assemble the necessary equipment
4. Position the patient in his/ her comfortable
position (mostly sitting position).
5. Pour the fluid (food) into the measuring jag as
prescribed.
6. Connect the syringe with the tube.
7. Hold syringe at angle so that air doesn’t enter
stomach and continue pouring the fluid into the
syringe or funnel.
04/29/2023 41
 Cont…
8. Hold syringe perpendicular so feeding can enter by
gravity.
9. After feeding rinse with water and remove the
syringe.
10. Cover the tip of the tube with sterile gauze using a
plastic band and attach to the dressing.
11. Apply light dressing over the stoma and tube.
12. Comfort patient; keep the head of the bed
elevated for at least 30minutes after procedure to
aid digestion.
13. Clean return used equipments
14. Wash hands and document procedure in the
client’s medical record
04/29/2023 42
NG Tube: Inserting a Nasogastric Tube

• Have client blow nose and encourage

swallowing of water if level of
consciousness and treatment plan permit.

• Lubricate first 4 inches of tube with water

soluble lubricant.

04/29/2023 MS 43
 Nasogastric intubation
• NG tube is a thin pleable plastic tube that can be
inserted in to a patients nose and advanced in to
stomach.
• Passing a tube through a nasal cavity down the
nasopharynx and oesophagus in to the stomach
• It can be ordered for gastric decompression,
gastric lavage or gastric feeding.
• Gastric decompression: relieves stomach and
intestine from pressure caused by accumulation of
air or fluid.

44
 Nasogastric intubation
• Gastric lavage: is irrigation of stomach content.
Incases of accidental poisoning and drug overdose,
quickly removal of gastric content is required.

• Gastric feeding: for patients who cannot obtain

adequate nourishment orally, liquid food can be
instilled in to stomach through nasogastric tube.
• Also known as enteral nutrition or gastric gavage.
• It provides physiological, safe, and economical
nutritional support.
45
 Nasogastric intubation
Purposes
- To maintain nutrition to clients unable to eat by
mouth or swallow a sufficient diet without aspirating
food or fluid into the lungs
- To administer medications
- before and after surgery
- To establish a means for suctioning stomach
contents to prevent gastric distention, and vomiting.
- To remove laboratory contents for laboratory
analysis
- To lavage (wash) the stomach in case of poisoning
or overdose of medication or gastric bleeding 46
 Nasogastric tube feeding
• Appropriate only when nutrients can be absorbed
from GI system.
Indication
Surgery
Abdominal distension
Poison
Unconscious
Severe dehydration
Diagnostic analysis

04/29/2023 47
 Cont’d…

Equipment
• NGT, (Ryle’s tube) plaster,
• Gauze
• Water soluble lubricant
• Disposable glove
• Glass of water
• 20 to 50 ml syringe
• Stethoscope
• Blue litmus paper
• Ink
• Spigot to close the tube
• Cotton applicator to clean nostril
• Waste receiver
• Rubber sheet and draw sheet
• 04/29/2023
Mouth wash tray 48
 Cont’d…
• Tongue depressor
• Flash light
• Basin with warm water or ice
• Denature cup
• Safety pin and rubber band
• Bath towel
• Normal saline
• Emesis basin( bowel)
• Clamper or artery forceps to clamp the tube to avoid air
entry

04/29/2023 49
Procedure
1. Explain the procedure to the patient
2. Wash hands and prepare equipments
3. Position:
• For conscious patient sitting or a semi-upright
position and support the head on a pillow
• It is often easier to swallow in this position and
gravity helps the passage of the tube
• For unconscious patient lying in the left lateral
position with the head slightly lower than the body.
• For infants and young children, do not hyper extend
or hyper flex the neck; may occlude air way but in
young person ask to hyper extend the neck
04/29/2023 50
 Cont…

4. Done examination glove

5. Drape plastic sheet and lower around patient’s neck.
6. Assess client’s necks
7. After hyperextend the head of the client observe the
patent of the tissues of the nostrils, including any
irritations or abrasions by using a flash light and
examine the nares for any obstructions or deformities
by asking the client to breathe through one nostril
while occluding the other
a. Check that the nostrils are patent by asking the
patient to sniff with one nostril closed

04/29/2023 51
 Cont’d…

b. Repeat with the other nostril. If necessary cleanse

the nostrils with water using cotton wool on
applicator.
8. Prepare the tube for insertion. If a rubber tube is
being used, place it on ice this stiffens the tub,
facilitating insertion. If a plastic tube is being used,
place it in warm water. This makes the tube more
flexible, facilitating insertion

04/29/2023 52
 Cont’d…

9. Use the tube to mark off the distance from the tip of
the client’s nose to the tip of the ear lobe and then to
the tip of the sternum.
• This distance varies among individuals.
• For infant and young children, measure then to the
point midway between the umbilicus and the xiphoid
process. Mark this length with adhesive tape /ink if the
tube does not have markings.

10. Lubricate about 15-20 cm of the tube with a water

soluble lubricant using a swab

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04/29/2023 54
04/29/2023 55
 Cont…
11. Insert the rounded end of the tube in hyper
extend neck in to the cleanest nostril and slide
it backwards and in wards along the floor of
the nose to the nasopharynx.
a. If any obstruction is felt, withdraw the tube
and try again in a slightly different direction or
use the other nostril.

04/29/2023 56
 Cont…

12. As the tube passes down in the

nasopharynx, ask the patient to start
swallowing and sipping water this will close
the glottis, enabling the tube to pass in to the
oesophagus.
a. Slight pressure is sometimes necessary to pass
tube but never forced against resistance,
because of the danger of injury

04/29/2023 57
 Cont’d…
13. Advance the tube through the pharynx, as the patient
swallow’s until the predetermined mark has been reached.
– While inserting the tube observe for patient condition
for Coils in the mouth by opening the mouth by tongue
depressor
– If client gag, stop passing the tube momentarily with
each wall insert 5 to 10 cm with each swallow.
– If client continues to gag and the tube does not
advance with each swallow, withdraw it slightly.
– If the patient shows signs of distress like gasping or
cyanosis, remove the tube immediately and try again
the procedures.

04/29/2023 58
 Cont’d…

14. Continue in advancing the tube until the

mark on and the tube reach his/her nostril.
15. Taping a tube to the bridge of the nose

04/29/2023 59
 Cont’d…

16. Check the position of the tube to confirm

that it is in the stomach by:-
A. Introducing 10-20ml of air in to the stomach
via the tube and check for a whooshing sound
using a stethoscope placed over the
epigastrium.
B. Aspirating the contents of the stomach with a
syringe. The aspirate turns blue litmus paper
to red.
C. Insert/immerse the tip of tube in the glass of
water and if you see bubble that show you are
in the lung.
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17. Clamp the end of the tube with clamper or
forceps or spigot
18. Secure the tube to the nostril and attach to
forehead with adhesive tape. Ensure patient is
comfortable.
19. Attach the tube to a suction source or feeding
apparatus as ordered
20. Assist the patient into position and comfort
21. Remove and clean the used equipment return it
in to proper place
22. Wash hands and dry
23. Document relevant information
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 A. Nasogastric tube medication administration
• The nurse checks the patency and placement
of a nasogastric tube before adding any water
or medications by performing the following
actions:
 Wash hands and done non sterile gloves.
 Unclamp the tube.
 Check the placement of the tube in the
stomach

04/29/2023 62
 Cont’d…

• If the nurse fails to hear the whooshing sound

and aspirates gastric contents, the tube may have
risen into the client’s esophagus ; do not
administer the medication until placement in
the stomach is verified.

 When different types of medications are

administered, each type is given separately, that
is compatible with the medication’s preparation.

04/29/2023 63
 Cont…

 The tube is flushed with 20 to 30 mL of

water after each dose.
 If a liquid form of a medication is not
available and the medication can be crushed, it
must first be reduced to a fine powder unless
the tube will become clogged

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B. Gastric aspiration
• is the withdrawal of fluid or gas from gastric
cavity by suctioning
• Gastric content analysis
It is examination of the contents of
stomach, to determine the quantity of acid
present
To ascertain the presence of blood, bile,
bacteria, and abnormal cells.

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 Purpose of gastric aspiration
1. To relieve stomach or intestinal distension following
abdominal surgery.
2. In case of GI obstruction to remove the stomach
content
3. To keep the stomach empty before an emergency
abdominal operation is done.
4. To aspirate the stomach contents for diagnostic
purpose e.g
– detect acid-fast bacillus in a client with
undiagnosed tuberculosis
– total absence of hydrochloric acid is diagnostic of
pernicious anaemia.
04/29/2023 66
 Equipments
1. Nasogastric tube (NGT)
2. Syringe with needle(2) 12. Gauze
3. 50ml syringe 13. Draw sheet, rubber sheet
14. Spigot
4. Towel
15. Stethoscope
5. Water with kidney dish
16. Water base lubricant
6. Specimen container 17. Scissor
7. Sphygmomanometer 18. Ink
8. Litmus paper 19. Histamine
9. Adhesive tape 20. Cotton applicator
21. Spatula
10. Chart
11. Tray
04/29/2023 67
 Cont’d…
Procedure of Gastric aspiration

After you Determine that the tube is in client’s

stomach,
 Place the tip of the tube in the water in kidney
dish; if bubbling happens it indicates that the
tube is in respiratory system, immediately
remove the tube.

04/29/2023 68
 Cont’d…
 Or aspirate 20-30ml of the content of the stomach
with syringe then test the content by using Litmus
paper. Gastric content is yellow to green in color and
usually presents in amounts greater than 10 ml.
 Take 20 cc syringe aspirate air and administer the air
through NG tube, place stethoscope on epigastric area
then listen to a gurgling sound. If you hear the sound
it means that the tube is with in the stomach.
 Chest x- ray

• After being sure that the tube is in the right position

secure the tube by taping to bridge of the client's nose
04/29/2023 69
 Cont…
1) Aspirate gastric fluid using 20-50 ml syringe and
collect specimen if needed, or aspirate with suction
machine or attach with bag or clamp end of tubing as
ordered.
2) Histamine will be given subcutaneously to stimulate
gastric secretions.
3) Continuously monitor the blood pressure to detect
hypotension.
4) Collect gastric specimen every 15 minutes for 1 hour.
5) Label the specimen to indicate specimen before and
after histamine injection
6) Comfort the patient
7) Clean or discard used equipments.
70
8) Record
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C. Gastric lavage
 Gastric lavage is the introduction of solution into
the stomach and removing gastric contents through
nasogastric tube for washing out the stomach.
Purpose
• To remove inserted poison, other than corrosive
substances like ammonia and mineral substances.
• To introduce ice water or normal saline solution in
tackling bleeding.
• To cleanse the stomach before operation.
• For diagnostic purposes.
• To relief congestion, nausea and vomiting .
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Indication
• Pyloric stenosis
• Poisoning
• Preoperative care
Equipments
1. Equipments for NG tube insertion
12. Suction machine (optional)
2. Measuring jug
3. 2-3 litters prescribed solution. 13. Labelled specimen container
14. Laboratory request form
4. IV stand
5. Tap water or ice if ordered 15. Charcoal tablets ( universal
antidote)
6. 50ml syringe
16. Emesis basin
7. Funnel
17. Tissue paper
8. Gloves
18. Drainage container
9. Rubber and cotton sheet
19. Vital sign instruments
10. Towel
20. Chart
11. Litmus paper

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 Cont’d…

Procedure of gastric lavage

1. Once you confirm proper placement of the tube,
begin gastric lavage by instilling about 250ml of
irrigating solution to assess the patient’s tolerance
and prevent vomiting.

 If you are using simple rubber tube for the lavage

a. Fill the small jug with water/ solution, measure and
pour gently until the funnel is empty, then invert over
the pail (the funnel is connected with the funnel end
of the oesophageal tube)
b. Take specimen, if required, and continue the process
until the returned fluid becomes clear and the
prescribed solution had been used.
04/29/2023 73
 Cont’d…

1. Instruct the client to take deep breath and hold it to close

epiglottis
2. Monitor patient’s vital signs, urine output, and level of
consciousness every 15 minutes and notify the physician for
any changes.
3. Give mouth wash
4. If ordered, gently remove the tube, feel the client’s tube,
and watch the respiration
5. Remove glove, hand wash, Clean or discard used
equipments.
6. Comfort the patient
7. Record the procedure, including the time, date, type of
irrigating solution and the amount of gastric contents
drained.
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D.Gastric Gavage
• Gastric gavage is providing nutritional supplement
when the patient is unable or not willing to take food
per mouth with normal GI tract functioning.
Purpose
1. To provide total supplemental nutrition
2. Restore fluid, electrolyte and acid base balance.
3. Reduce or eliminate catabolism and negative nitrogen
balance.
Precaution
• Severe pancreatitis
• Enterocutaneous fistulae
•04/29/2023
GI ischemia
75
Contra indication
• Diffused peritonitis
• Intestinal obstruction that prohibits normal bowel functioning
• Intractable vomiting; paralytic ileus
• Severe diarrhea
Patient assessment
1. Assess the client for signs of gastric distress, such as nausea,
vomiting, and cramping, to determine the client’s tolerance for
the tube feeding.
2. Assess the feeding tube placement every 4 hours to confirm
tube placement in the GI tract.
3. Assess the client’s respiratory status to evaluate for
pulmonary aspiration of gastric contents.
4. Assess the client’s ongoing nutritional status to evaluate the
effectiveness of the tube feeding.
5. Assess the client’s intake and output to evaluate feeding
impossible.
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Equipment
1. NG tube
2. Tap water
3. Formula /Liquid food ( at room temperature)
4. IV stand
5. Tray
6. Clean Glove
7. 50ml syringe
8. Funnel
9. Disposable gavage bag and tubing
10. Towel
11. Tissue paper
12. Dirty receiver
13. Chart

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Procedure
1. Explain the procedure to the patient, provide privacy
2. Wash hands and assemble the necessary equipments.
3. Assist the client to a fowler's position in bed or a
sitting position in a chair, the normal position for
eating
 If this position is contraindicated, a slightly elevated right
side lying position is acceptable.
 These position help/ enhance the gravitational flow of the
solution & prevent aspiration.
4. Assess the client for feelings of abdominal distension,
blenching, loose stools, flatus or plain; bowel sounds
and allergies to foods.
04/29/2023 78
 Cont’d…

5. If NG tube is not in place follow the NG tube

insertion procedure and insert the tube and secure it.
6. Confirm correct placement of the tube
7. Cover the patient’s chest with the towel to protect
him/her from spills of food.
8. Aspirate stomach contents to determine amount of
residual and measure it.
 If the residual is over 50-100 ml in adults and 10 ml
or more infants, hold the feeding until residual
diminishes or subtract the withdrawn amount from
the total feeding and administer the rest. All these
are based on the policy agency.
04/29/2023 79
 Cont…

9. Reinstall the gastric contents to the stomach to

prevent electrolyte imbalance.
10. Before the feeding solution has drained from
the neck of the bottle, instill 50-60 ml of water
through the tube, to prevent tube feeding
syndrome and further blockage.
11. Remove air from the feeding tubes and attach
it to the nasogastric tubes and to prevent air
from entering to the stomach, never allow the
syringe or the gavage bag to empty completely.

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 Cont…

12. Hang bottle on IV stand beside patient and run

the food through the giving set or if a syringe is
to be used remove plunger from barrel of
syringe and attack barrel to nasogastric tube.

Deliver feeding over the desired length of time (as

ordered). Usually 200-350 ml over 10-15 minutes is
given.
Replace any formula administered by an open
system every 4 hours with fresh formula. Formula
should be at room temperature or cool (not cold).

04/29/2023 81
 Cont…

13. After the administration of the appropriate amount of

food, flush the tube by adding about 60ml of water to
the syringe. This maintains the patency of the tube by
removing excess food particles which could block the
tube.
14. If you are administering a continuous feeding, flush
the tube every 4hours to help prevent tube occlusion.
15. To discontinue the NG tube feeding disconnect the
syringe from the feeding tube.
16. Close the tip of the NG tube with its plug cap before all
of the rinse solution has run through to prevent leakage
and contamination.

04/29/2023 82
 Cont…
17. Leave the patient in semi sitting position or
slightly elevated right lateral position for at
least 30minutes.
18. Communicate with your patient.
19. Clean and return used equipments.
20. Wash your hand
21. Record the amount given and the patient’s
general condition.

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Complications
• Diarrhoea – due to hyper osmolar feeding,
rapid infusion, bacteria contaminated feedings,
lactase deficiency and food allergies etc.
• Nausea/ vomiting- due to Change in rate of
feeding, offensive smell, inadequate gastric
emptying.
• Cramping/ gas- due to air in tube.
• Constipation- high milk content, low fiber
intake, inadequate fluid intake.

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 Complication….
• Aspiration pneumonia- due to improper tube
placement, flat in bed, too large tube etc.
• Tube displacement- due to excessive coughing/
vomiting, tracheal suctioning etc.
• Tube obstruction- due to inadequate flushing/ formula
rate.
• Naso pharengeal irritation- due to tube position and
large tubes.
• Hyperglycaemia- glucose intolerance and high
carbohydrate feeding content.
04/29/2023 85
.Removal of a Nasogastric Tube
• Nasogastric tube removal is the process of withdrawing the
nasogastric tube which was placed in client’s stomach for
different purpose.
• When the physician determines that the client’s nutritional
status no longer warrants/necessitate/ EN therapy or the
need to provide decompression of the gastric contents, the
nasogastric tube is removed.
• If the client is connected to suction for decompression, the
physician may prescribe clamping the tubing for several
hours prior to removal, to ensure a functioning GI tract.

04/29/2023 86
 Equipment:
1. Don sterile gloves
2. Tube plug or clamp
3. Towel, washcloth
4. Paper towel
5. Receptacle for contaminated items

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Procedure
1. Hand wash
2. Verify the physician’s prescription.
3. Check the client’s armband and explain the procedure.
4. Provide for privacy.
5. Wash hands and don gloves.
6. Place the client in a high Fowler’s position and adjust the
height of the bed to a comfortable working position.
7. Place the towel across the client’s chest.
8. Clamp or plug the tube and unpin the tube from client’s
gown.
9. Remove the tape securing the tube from the client’s nose.

04/29/2023 88
 Cont…
10. Hold the paper towel open in your non dominant hand under
the client’s chin; with your dominant hand, grasp and pinch
the tube near the nostril, and remove the tube with a steady,
continuous pull, allowing the tube to fall into the paper towel.
11. Dispose of the tube and paper towel in the receptacle.
12. Clean the client’s nares and provide oral hygiene.
13. Position the client comfortably, place call light in easy reach,
and return bed to a low position.
14. Remove gloves, place in receptacle, and dispose of
receptacle in accord with agency policy.
15. Wash hands and document procedure in the client’s medical
record

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 Any Questions?

04/29/2023 MS 90
 !
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04/29/2023 MS 91