Gastric lavage. For medical students personal

Gastric lavage explainable

1. Preparation of Patient and Assisting with the Following Procedures: Gastric Lavage, NG Tube Feeding, Gastrostomy Feeding, Fractional Test Meal, Ileostomy and Colostomy Care

2. NG TUBE   Nasogastric tube is also known as Ryle's tube

3. Generally,

4. Nursing Considerations Provide oral and skin care.  Give mouth rinses and apply lubricant to the patient’s lips and nostril. Using a water-soluble lubricant, lubricate the catheter until where it touches the nostrils because the client’s nose may become irritated and dry. Verify NG tube placement.  Always verify if the NG tube placed is in the stomach by aspirating a small amount of stomach contents. An X-ray study is the best way to verify placement. Wear gloves.  Gloves must always be worn while starting an NG because potential contact with the patient’s  blood  or body fluids increases especially with inexperienced operator. Face and  eye  protection.  On the other hand, face and eye protection may also be considered if the risk for vomiting is high. Trauma protocol calls for all team members to wear gloves, face and eye protection and gowns.

5. CONTRAINDICATION Severe Facial and neck Trauma Esophageal stricture Recent banding of Esophageal varices Coagulation abnormalities

6. Preparation of Patient and Assisting with Gastric Lavage

7. Gastric Lavage A lso called stomach pumping or gastric irrigationor stomach wash It is the process of cleaning out the content of the stomach. It involve aspiration of the stomach content and washing out by means of a gastric tube. Gastric lavage is used to remove unabsorbed poison or drug ingestion It is generally ineffective if more than 60 minutes have passed and the procedure may delay administration of activated or charcoal antidotes. NB; Gastric lavage has small place in modern treatment of poisoning and some authorities suggest that it NOT t o be employed routinely, if ever in the management of poisonings situations

8. PURPOSES For urgent removal of ingested substances in order to decrease systemic absorption To empty the stomach before endoscopic procedures To obtain casts of epithelial cells for bacteriological studies To diagnose gastric hemorrhage and arrest hemorrhage Potentially life threating poisoning and presentation in an hour Large salicylate poisoning Ingestion of too much alcohol Before surgery, to clear the content of the GIT

9. CONTRAINDICATIONS Poisons that have effective antidote In the presence of seizures For patients who have a compromised, unprotected airway Ingestion of corrosive substances Esophageal disease

10. Requirements (1) Syringes, 2 or more, 50cc catheter tip. (2) Washbasins, 2 (to collect used solution). (3) Bath towels. (4) large bore nasogastric tube (5) Emesis basin. (6) Paper tissues (7) Graduated container for measuring prescribed lavage solution (usually, normal saline solution). (9) Suction equipment readily available (10) large plastic funnel with adapter (11) Mackintosh and cover

11. Preparation of patient Assess airway patency and gag reflex Check oxygen saturation Pt with unprotected airway, should be intubated Check vitals signs –baseline Get an IV access Toxicology screening –blood /urine specimen for poisoning test Measure abdominal girth Remove dentures if any Position client (fowlers /semi fowlers for ng tube placement then lateral position for lavage If there is already NG tube, check for proper placement before lavage

12. Procedure Explain procedure Protect airway (endotracheal intubation if the client stuporous or comatose) Place patient in the left lateral position to decrease passage of gastric contents into the duodenum during the lavage and minimize possibility of aspiration into the lungs Insert a large bore lumen orogastric tube ( follow steps for passing NG tubes) Aspirate stomach contents with the syringe attached to the tube, before instilling water or antidote. Save the specimen for analysis Use a small cycle lavage of 50 to100 ml and then aspirate Small amount of saline is administered and through a siphoning action removed again. Saline is preferred to water especially in children due the risk of developing hyponatremia Lavage is rarely indicated beyond 10 minute , unless tablets are still being actively being returned, in which case lavage procedure is repeated until the returns are clear At the completion of the lavage, pinch off the tube during removal or maintain suction while the tube is being withdrawn (pinching off the tube prevents aspiration and the initiation of the gag reflex. Keep the patient’s head lower than the body also help prevent initiation of the gag reflex Make patient comfortable Document and report findings

13. Complications Aspiration of gastric content Discomfort Esophageal rupture Mechanical injury/trauma to tissue of the throat, sinuses ,esophagus and stomach Profound bradycardia, laryngospam and hyponatremia Wrong placement.  Unwanted scenarios such as wrong placement of an NG tube into the lungs will allow food and medicine pass through it that may be fatal to the patient. Other complications include:  abdominal  cramping  or swelling from feedings that are too large,  diarrhea , regurgitation of the food or medicine, a tube obstruction or blockage, a tube perforation or tear, and tubes coming out of place and causing additional complications Prolonged use can lead to conditions such as sinusitis, infections, and ulcerations on the tissue of your sinuses, throat, esophagus, or stomach.

14. NG Tube Feeding

15. Indication Dysphagia with frequent aspiration is the most common indication for use of tube feedings in the elderly. Impaired swallowing/sucking Facial or esophageal structural abnormalities Anorexia related to a chronic illness Eating disorders Increased nutritional requirements, Congenital anomalies Primary disease management. Enteral feeding tubes can be used to: Administer bolus, intermittent feeds and continuous feeds Medication administration Facilitate free drainage and aspiration of the stomach contents Facilitate venting/decompression of the stomach Stent the oesophagus

16. Supplies and Equipment Gloves Feeding pump (if ordered) Clamp (optional) Feeding solution Large catheter tip syringe (30 mL or larger) Feeding bag with tubing Water Measuring cup Other optional equipment (disposable pad, pH indicator strips, water-soluble lubricant, paper towels

17. Medication Administration through NGT Nursing Consideration: Use medications in liquid form whenever possible. If pills or capsules must be used, crush to a fine powder and dissolve in warm water prior to administering. DO NOT crush extended release, enteric coated and sublingual or buccal forms of medication . Most liquid medications may be diluted with water before administration to minimize development of diarrhea and gastric irritation.

18. EQUIPMENT PPE 2. Stethoscope 3. >35 mL syringe i.e. Catheter or Luer tip (adults) – pediatrics may use smaller due to smaller volume used 4. pH test strips 5. Sterile Water (SW) 6. Medication(s) as ordered

19. PROCEDURE 1. Flush feeding tube using push pause technique with 25 mL SW following EACH medication administration. NOTE: PEDIATRICS: Flush with 5-10 mL of water. 2. Administer dissolved/diluted medication via syringe into feeding tube/medication port. 3. Administer each medication separately to prevent drug interactions. 4. Clamp NG following medication administration NOTE: Contact pharmacy for length of time to clamp tube. 5. : Flush with water after feed Document

20. Types of Feeding Bolus Feeding Possibly feed in semi fowlers or upright position during feeding and for at least 30 minutes after the feed to reduce the risk of aspiration. Feed should be at room temperature Check placement before feeding Flush tube with water prior and after feeding Using a syringe for a bolus feed Remove the plunger from the syringe and place the tip of the syringe into the NG tube connector at end of the enteral tube. Holding the syringe and enteral tube straight, pour the prescribed amount of feed into the syringe. Let it flow slowly through the tube e.g. 250ml over 20 minutes. Pour15-30MLS / the prescribed amount of water into the syringe and allow to flow through to flush the feeding tube appropriately.

21. Types of Feeding Cont. 2. Continuous feeding: is defined as delivering enteral nutrition with constant speed for 24 h via nutritional pump 3. Intermittent bolus feeding is defined as delivering enteral nutrition multiple times, generally giving 15–30 min every 2–3 h by gravity or electric pump.

22. Administering bolus feed Administering cont. feed

23. Nursing consideration for client on NG Tube Perform oral hygiene daily Check tube placement Inspect mouth with pen light (observe tube behind the tongue) Gastric aspirate for PH testing (1-4) Auscultatory method (push about 10-30mls air and auscultate abdomen for rushing sounds) Assess visual characteristic of feeding tube aspirate confirmed via x-ray Maintain tube patency: flush with water before and after feeding Use warm water to declogg obstructed feeding tube Monitor client for abdominal distension, abdominal pains and discomfort

24. GASTROSTOMY FEEDING

25. Introduction A gastrostomy is a surgically formed artificial opening into the stomach known as a stoma. It is also called a G-tube They are commonly surgically inserted endoscopically through the abdominal wall, and held in place by an internal balloon or bumper and external fixator. Gastrostomy feeding is a successful method of enteral feeding providing daily nutritional requirements in specialist liquid form directly into a patient’s stomach via a flexible tube.

26. Indication It is considered for patients who need long-term (4 weeks or more) enteral tube feeding. Birth defects of the mouth, esophagus, or stomach eg. esophageal atresia or tracheal esophageal fistula Problems with sucking and/or swallowing, for example in patients debilitated by stroke or dementia NB: Nasogastric tube is preferred for short-term feeding, while gastrostomy or jejunostomy is indicated for long-term or permanent nutritional support.

27. CONT. The tubes come in a variety of types and are referred to according to the type inserted. The commonest types are percutaneous endoscopic gastrostomy (PEG) tubes and low-profile gastrostomy tubes, e.g. Mic-key button ™

28. Methods of feeding via a gastrostomy There are two main methods of feeding via a gastrostomy as detailed below: Bolus feeding : A volume of liquid feed given usually via a gravity set over a short duration, e.g. 15–20 minutes. Continuous feed: This is a feed given via an electronic feeding pump, which allows clinicians to deliver set amounts of enteral formula in a consistent manner, over a desired duration of time.

29. Preparation and equipment Before administration of feed, preparation is paramount, therefore simple steps should be adopted as detailed below: Collect the appropriate equipment, e.g. syringes (20–50 ml), gravity feeding set, pump, pump feeding set, gloves, apron, water for flush. Make feed or use appropriate pre-made feed. Check the expiry date of the feed. Gain informed consent from patient or parent prior to administration of feed. Assess stoma for signs of infection

30. Procedure for bolus feed Wash hands. Put on gloves and apron. Ensure the patient is sitting up or elevated as much as their condition dictates, to help prevent vomiting and aspiration during the feed and for a period of time after the feed is completed. Flush the gastrostomy with approx. 10 ml of water to confirm the patency of the tube. Open the gravity feeding pack, which should consist of: 60 ml open-ended syringe; extension tubing with a roller clamp system; Luer lock connector end, with purple and clear capped end. Taking the tubing, ensure the clamp is rolled in a downward position, connect the bladder tip syringe on to the open end of the tubing. Take your feed, pour enough feed into the syringe to cover the stretch of the tubing and a little bit more approx. 15 ml. Over the sink, roll the clamp slowly into the upward position and gradually prime the tubing till it reaches the Luer lock end. Ensure the clamp is in the downward position. Attach the Luer lock end to the appropriate enteral feeding port on the gastrostomy. Unclamp, then clamp on the gastrostomy tube. Hold the syringe with the feed up and gradually release the clamp until fully open. Reducing the height of where the syringe is held will slow down the speed at which the feed is administered. Once the volume of feed is delivered, clamp down on the administration tube before the milk reaches the end, and close the clamp on the gastrostomy extension. Remove the giving set and flush the gastrostomy using an oral 20 ml syringe filled with a minimum of 10 ml water (sterile or cooled boiled water for children under the age of one).

31. Procedure for a pump feed Collect all the relevant equipment required for the feed as per the bolus feed, including the feeding pump. Wash hands . Put on gloves and apron. Ensure the patient is sitting up or elevated as much as their condition dictates, to help prevent vomiting and aspiration during the feed and for a period of time after the feed is completed. Flush the gastrostomy with approx. 10 ml of water to confirm the patency of the tube. Take the feed and the feeding set. The tubing extension will have a purple screw top, with a sharp pointed skewer, a length of tubing with a plastic chamber below the cap and a purple kite-shaped junction half-way down the tubing with a squeezable priming attachment. The feed will either need to be decanted into a plastic bottle that will be provided with the extension or will come in a pre-made bottle with a foil seal. Connect the tubing onto the feed. Half-fill the plastic chamber with milk by squeezing the sides. Hold the milk up in the air, and using the squeezable primer, push until the tubing is fully purged of air and full of milk, ensuring to stop just after the junction. In accordance with the manufacturer’s guidelines for the pump, attach the bottle/bag to the pump and set the rate and the total volume of feed to be delivered. Ensure the pump is set to hold. Attach the Luer lock end to the appropriate enteral feeding port on the gastrostomy. Unclamp, then clamp on the gastrostomy tube. Ensure the clamp is released on the gastrostomy extension if relevant, and turn the pump dial to run. Once the volume of feed is delivered, close the clamp on the gastrostomy extension and detach from the pump. Remove the giving set and flush the gastrostomy using an oral 20 ml syringe filled with a minimum of 10 ml water (sterile or cooled boiled water for children under the age of one).

32. NURSING CARE /CONSIDERATION Daily Anthropometric measurements : height, weight, triceps skinfold, subscapular skinfold, arm circumference, abdominal circumference, calf circumference, knee height, and elbow breadth Nutritional assessment of recording any weight change; determining albumin, prealbumin level

33. FRACTIONAL TEST MEAL

34. Indication Discuss

35. Ileostomy and Colostomy Care

36. Stoma Care Wash your skin with warm water and dry it well before you attach the pouch. Avoid skin care products that contain alcohol. These can make your skin too dry. Do not use products that contain oil on the skin around your stoma. ... Use fewer, special skin care products to make skin problems less likely.