Chapter 44, Digestive and Gastrointestinal Treatment Modalities, pp. 1243-1263

A patient has had a gastrostomy tube inserted. What does the nurse anticipate the initial fluid nourishment will be after the insertion of the gastrostomy tube? 1. High-calorie liquids 2. Distilled water 3. 10% glucose and tap water 4. Milk

3. 10% glucose and tap water The first fluid nourishment is administered soon after tube insertion and can consist of a sterile water or normal saline flush of at least 30 mL. Tap water may be used during medication administration or tube feedings.

A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. It is best for the nurse to 1. Place the nasogastric tube to the level of the esophagus. 2. Reinsert the nasogastric tube to the stomach. 3. Notify the surgeon about the tube's removal. 4. Document the discontinuation of the nasogastric tube.

3. Notify the surgeon about the tube's removal. If the nasogastric tube is removed accidently in a client who has undergone esophageal or gastric surgery, it is usually replaced by the physician. Care is taken to avoid trauma to the suture line. The nurse will not insert the tube to the esophagus or to the stomach in this situation. The nurse needs to do more than just document its removal. The nurse needs to notify the physician who will make a determination of leaving out or inserting a new nasogastric tube.

The client is experiencing swallowing difficulties and is now scheduled to receive a gastric feeding. She has the following oral medications prescribed: furosemide (Lasix), digoxin, enteric coated aspirin (Ecotrin), and vitamin E. The nurse withholds 1. vitamin E 2. digoxin 3. enteric coated aspirin 4. furosemide

3. enteric coated aspirin Simple compressed tablets (furosemide, digoxin) may be crushed and dissolved in water. Soft gelatin capsules filled with liquid (vitamin E) may be opened, and the contents squeezed out. Enteric coated tablets (enteric coated aspirin) are not to be crushed and a change in the form of the medications is required.

As part of the process of checking the placement of a nasogastric tube, the nurse checks the pH of the aspirate. Which pH finding would indicate to the nurse that the tube is in the stomach? 1. 10 2. 6 3. 8 4. 4

4. 4 Gastric secretions are acidic and have a pH ranging from 1 to 5. Intestinal aspirate is typically 6 or higher; respiratory aspirate is more alkaline, usually 7 or greater.

The nurse is to discontinue a nasogastric tube that had been used for decompression. The first thing the nurse does is 1. Withdraw the tube gently for 6 to 8 inches. 2. Remove the tape from the nose of the client. 3. Provide oral hygiene. 4. Flush with 10 mL of water.

4. Flush with 10 mL of water. Before a nasogastric tube is removed, the nurse flushes the tube with 10 mL of water or normal saline to ensure that the tube is free of debris and away from the gastric tissue. The tape keeps the tube in the correct position while flushing is occurring and is then removed from the nose. The nurse then withdraws the tube gently for 6 to 8 inches until the tip reaches the esophagus, and then the remainder of the tube is withdrawn rapidly from the nostril. After the tube is removed, the nurse provides oral hygiene.

Bolus feeding

a feeding given into the stomach in large amounts and at designated intervals

percutaneous endoscopic gastrostomy (PEG)

a feeding tube inserted endoscopically into the stomach

Radiopaque

can be easily localized on x-ray

Lavage

flushing of the stomach with water or other fluids with a gastric tube to clear it

Osmolality

ionic concentration of fluid

Enteral nutrition

nutritional formula feedings infused through a tube directly into the gastrointestinal tract

Enteric

of or relating to the intestines

Gastroparesis

partial paralysis of the stomach that results in decreased gastric motility and emptying

Cyclic feeding

periodic infusion of feedings given over 8 to 18 hours

dumping syndrome

physiologic response to rapid emptying of gastric contents into the small intestine, manifested by nausea, weakness, sweating, palpitations, syncope, and possibly diarrhea

decompression (gastric/intestinal)

removal of gastric or intestinal contents to prevent gas and fluid distention

Aspiration

removal of substance by suction or the inhalation of fluids or foods into the trachea and bronchial tree

Jejunum

second portion of the small intestine, which extends from the duodenum to the ileum

Lumen

the channel within a tube or catheter

duodenum

the first part of the small intestine, which arises from the pylorus of the stomach and extends to the jejunum

Intubation

the insertion or placement of a tube into a body structure or passageway

Orogastric tube

tube inserted through the mouth into the stomach

nasoduodenal tube

tube inserted through the nose into the proximal portion of the small intestine (i.e., duodenum)

Nasojejunal tube

tube inserted through the nose into the second portion of the small intestine (i.e., jejunum)

Peristalsis

wavelike movement that occurs involuntarily in the alimentary canal

A client is receiving parenteral nutrition (PN) through a peripherally inserted central catheter (PICC) and will be discharged home with PN. The home health nurse evaluates the home setting and makes a recommendation when noting the following: 1. Electricity that loses power, usually for short duration, during storms 2. No land line; cell phone available and taken by family member during working hours 3. Little food in the working refrigerator 4. Water of low pressure that can be obtained through all faucets

2. No land line; cell phone available and taken by family member during working hours A telephone is necessary for the client receiving PN for emergency purposes. Water, refrigeration, and electricity are available, even if the circumstances are not optimal.

The primary source of microorganisms for catheter-related infections are the skin and the 1. catheter tubing. 2. catheter hub. 3. IV fluid bag. 4. IV tubing.

2. catheter hub. The primary sources of microorganisms for catheter-related infections are the skin and the catheter hub. The catheter site is covered with an occlusive gauze dressing that is usually changed every other day.

The nurse prepares to administer all of a client's medications via feeding tube. The nurse consults the pharmacist and/or physician when the nurse notes which type of oral medication on the client's medication administration record? 1. buccal or sublingual tablets 2. soft, gelatin capsules filled with liquid 3. simple compressed tablets 4. enteric-coated tablets

4. enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change in the form of medication is necessary for clients with tube feedings. Simple compressed tablets may be crushed and dissolved in water for clients receiving oral medications by feeding tube. Buccal or sublingual tablets are absorbed by mucous membranes and may be given as intended to the client undergoing tube feedings. The nurse may make an opening in the capsule and squeeze out contents for administration by feeding tube.

Central venous access device (CVAD)

a device designed and used for administration of sterile fluids, nutrition formulas, and medications into central veins

peripherally inserted central catheter (PICC)

a device inserted into a peripheral vein and designed and used for administration of sterile fluids, nutrition formulas, and medications into central veins

Nasogastric (NG) tube

tube inserted through the nose into the stomach

Nasoenteric Tube

tube inserted through the nose into the stomach and beyond the pylorus into the small intestine

Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the: 1. Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. 2. The patient cannot experience the deprivational stress of not swallowing. 3. Digestive process occurs more rapidly as a result of the feedings not having to pass through the esophagus. 4. Feedings can be administered with the patient in the recumbent position.

1. Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact. Regurgitation and aspiration are less likely to occur with a gastrostomy than with NG feedings.

The most significant complication related to continuous tube feedings is 1. a disturbance of intestinal and hepatic metabolism. 2. an interruption in fat metabolism and lipoprotein synthesis. 3. the increased potential for aspiration. 4. the interruption of GI integrity.

3. the increased potential for aspiration. Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the client receiving continuous tube feedings. Tube feedings preserve GI integrity by intraluminal delivery of nutrients. Tube feedings preserve the normal sequence of intestinal and hepatic metabolism. Tube feedings maintain fat metabolism and lipoprotein synthesis.

Which condition is caused by improper catheter placement and inadvertent puncture of the pleura? 1. pneumothorax 2. sepsis 3. air embolism 4. fluid overload

1. pneumothorax A pneumothorax is caused by improper catheter placement and inadvertent puncture of the pleura. Air embolism can occur from a missing cap on a port. Sepsis can be caused by the separation of dressings. Fluid overload is caused by fluids infusing too rapidly.

The nurse is inserting a nasogastric tube for a patient with pancreatitis. What intervention can the nurse provide to allow facilitation of the tube insertion? 1. Spray the oropharynx with an anesthetic spray. 2. Allow the patient to sip water as the tube is being inserted. 3. Have the patient maintain a backward tilt head position. 4. Have the patient eat a cracker as the tube is being inserted.

2. Allow the patient to sip water as the tube is being inserted. During insertion, the patient usually sits upright with a towel or other protective barrier spread in a biblike fashion over the chest. The nostril may be swabbed or the oropharynx sprayed with an anesthetic agent to numb the nasal passage and suppress the gag reflex. The tip of the patient's nose is tilted upward, and the tube is aligned to enter the nostril. When the tube reaches the nasopharynx, the patient is instructed to lower the head slightly and, if able, to begin to swallow as the tube is advanced. The patient may also be encouraged to sip water through a straw to facilitate advancement of the tube if this action is not contraindicated.

A client with a gastrojejunostomy is beginning to take solid food. Which finding would lead the nurse to suspect that the client is experiencing dumping syndrome? 1. Hyperglycemia 2. Diarrhea 3. Slowed heart beat 4. Dry skin

2. Diarrhea Clients with a gastrojejunostomy are at risk for developing the dumping syndrome when they begin to take solid food. This syndrome produces weakness, dizziness, sweating, palpitations, abdominal cramps, and diarrhea, which result from the rapid emptying (dumping) of large amounts of hypertonic chyme (a liquid mass of partly digested food) into the jejunum. This concentrated solution in the gut draws fluid from the circulating blood into the intestine, causing hypovolemia. The drop in blood pressure can produce syncope. As the syndrome progresses, the sudden appearance of carbohydrates in the jejunum stimulates the pancreas to secrete excessive amounts of insulin, which in turn causes hypoglycemia.

The nurse observes dry mucous membranes in a client who is receiving tube feedings after an oral surgery. The client also complains of unpleasant tastes and odors. Which of the following measures should be included in the client's plan of care? 1. Keep the feeding formula refrigerated. 2. Provide frequent mouth care. 3. Flush the tube with water before adding the feedings. 4. Ensure adequate hydration with additional water.

2. Provide frequent mouth care. Frequent mouth care helps to relieve the discomfort from dryness and unpleasant odors and tastes. It can be done with the help of ice chips and analgesic throat lozenges, gargles, or sprays. Adequate hydration is essential. If urine output is less than less than 500 mL/day, formula and additional water can be given as ordered. Keeping the feeding formula refrigerated and unopened until it is ready for use and flushing the tube with water before adding feedings are measures to protect the client from infections.

A patient is receiving continuous tube feedings. The nurse would maintain the patient in which position at all times? 1. High Fowler's with the patient sitting erect 2. Semi-Fowler's with the head of the bed elevated 30 to 45 degrees 3. Supine with a small pillow under the patient's head 4. Side-lying with the head slightly lower than the chest

2. Semi-Fowler's with the head of the bed elevated 30 to 45 degrees For the patient receiving continuous enteral feedings, the nurse would position the patient in the semi-Fowler's position with the head of the bed elevated 30 to 45 degrees at all times to reduce the risk of reflux and aspiration. This is the only appropriate patient position.

The nurse is inserting a Levin tube for a patient for gastric decompression. The tube should be inserted to 6 to 10 cm beyond what length? 1. The distance determined by measuring from the tragus of the ear to the xiphoid process 2. The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process 3. A point that equals the distance from the nose to the xiphoid process 4. A length of 50 cm (20 in)

2. The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process Before inserting the tube, the nurse determines the length that will be needed to reach the stomach or the small intestine. A mark is made on the tube to indicate the desired length. This length is traditionally determined by (1) measuring the distance from the tip of the nose to the earlobe and from the earlobe to the xiphoid process, and (2) adding up to 15 cm (6 in) for NG placement or at least 20 to 25 cm (8 to 10 in) or more for intestinal placement.

To ensure patency of central venous line ports, diluted heparin flushes are used 1. when the line is discontinued. 2. daily when not in use. 3. with continuous infusions. 4. before drawing blood.

2. daily when not in use. Daily instillation of dilute heparin flush when a port is not in use will maintain the port. Continuous infusion maintains the patency of each port. Heparin flushes are used after each intermittent infusion. Heparin flushes are used after blood drawing to prevent clotting of blood within the port. Heparin flush of ports is not necessary if a line is to be discontinued.

A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use? 1. 10-mL 2. 5-mL 3. 30-mL 4. 20-mL

3. 30-mL When small-bore feeding tubes for continuous tube feedings are used and irrigated after administration of medications, a 30-mL or larger syringe is necessary, because the pressure generated by smaller syringes could rupture the tube.

The nurse is caring for a patient who has dumping syndrome from high carbohydrate foods being administered over a period of less than 20 minutes. What is a nursing measure to prevent or minimize the dumping syndrome? 1. Administer the feeding with about 100 mL of fluid to dilute the high carbohydrate concentration. 2. Administer the feeding by bolus to prevent continuous intestinal distention. 3. Administer the feeding with the patient in semi-Fowler's position to decrease transit time influenced by gravity. 4. Administer the feeding at a warm temperature to decrease peristalsis.

3. Administer the feeding with the patient in semi-Fowler's position to decrease transit time influenced by gravity. The following strategies may help prevent some of the uncomfortable signs and symptoms of dumping syndrome related to tube feeding: Slow the formula instillation rate to provide time for carbohydrates and electrolytes to be diluted. Administer feedings at room temperature, because temperature extremes stimulate peristalsis. Administer feeding by continuous drip (if tolerated) rather than by bolus, to prevent sudden distention of the intestine. Advise the patient to remain in semi-Fowler's position for 1 hour after the feeding; this position prolongs intestinal transit time by decreasing the effect of gravity. Instill the minimal amount of water needed to flush the tubing before and after a feeding, because fluid given with a feeding increases intestinal transit time.

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must remain alert for: 1. manifestations of hypoglycemia. 2. manifestations of electrolyte disturbances. 3. diaphoresis, vomiting, and diarrhea. 4. constipation, dehydration, and hypercapnia.

3. diaphoresis, vomiting, and diarrhea. The nurse must monitor for diaphoresis, vomiting, and diarrhea because these signs suggest an intolerance to the ordered enteral feeding solution. Other signs and symptoms of feeding intolerance include abdominal cramps, nausea, aspiration, and glycosuria. Electrolyte disturbances, constipation, dehydration, and hypercapnia are complications of enteral feedings, not signs of intolerance. Hyperglycemia, not hypoglycemia, is a potential complication of enteral feedings.

The client is on a continuous tube feeding. The nurse determines the tube placement should be checked every 1. 24 hours. 2. hour. 3. shift. 4. 12 hours.

3. shift. Each nurse caring for the client is responsible for verifying that the tube is located in the proper area for continuous feeding. Checking for placement each hour is unnecessary unless the client is extremely restless or there is basis for rechecking the tube due to other client activities. Checking for placement every 12 or 24 hours does not meet the standard of care for the client receiving continuous tube feedings.

The nurse is inserting a nasogastric tube for a patient with pancreatitis. What intervention can the nurse provide to allow facilitation of the tube insertion? 1. Spray the oropharynx with an anesthetic spray. 2. Have the patient maintain a backward tilt head position. 3. Have the patient eat a cracker as the tube is being inserted. 4. Allow the patient to sip water as the tube is being inserted.

4. Allow the patient to sip water as the tube is being inserted. During insertion, the patient usually sits upright with a towel or other protective barrier spread in a biblike fashion over the chest. The nostril may be swabbed or the oropharynx sprayed with an anesthetic agent to numb the nasal passage and suppress the gag reflex. The tip of the patient's nose is tilted upward, and the tube is aligned to enter the nostril. When the tube reaches the nasopharynx, the patient is instructed to lower the head slightly and, if able, to begin to swallow as the tube is advanced. The patient may also be encouraged to sip water through a straw to facilitate advancement of the tube if this action is not contraindicated.

The nurse conducts discharge education for a client who is to go home with parenteral nutrition (PN). The nurse determines the client understands the education when the client indicates a sign and/or symptom of metabolic complications is 1. elevated blood pressure. 2. increased urination. 3. decreased pulse rate. 4. loose, watery stools.

4. loose, watery stools. When the client indicates that loose, watery stools are a sign/symptom of metabolic complications, the nurse evaluates that the client understands the teaching of metabolic complications. Signs and symptoms of metabolic complications from PN include neuropathies, changes in mental activity, diarrhea, nausea, skin changes, and decreased urine output.

Stylet

a stiff wire placed in a catheter or other tube that allows the tube to maintain its shape during insertion

Total Nutritent admixture (TNA)

an admixture of lipid emulsions, proteins, carbohydrates, electrolytes, vitamins, trace minerals, and water

intravenous fat emulsion (IVFE or lipid)

an oil-in-water emulsion of oils, egg phospholipids, and glycerin; also referred to as intravenous lipid emulsion

Stoma

artificially created opening between a body cavity (e.g., stomach or intestine) and the body surface

Parenteral nutrition (PN)

method of supplying nutrients to the body by an intravenous route

Jejunostomy

surgical creation of an opening into the jejunum for the purpose of administering fluids, nutrition formulas, and medications

Gastrostomy

surgical creation of an opening into the stomach for the purpose of administering fluids, nutrition formulas, and medications or for decompression and drainage of stomach contents