Gastrointestinal Tubes

• NG tubes (nasoduodenal, nasojejunal)

• Gastrostomy & jejunostomy
• Intestinal tubes
• Esophageal & gastric tubes
• Lavage tubes
 Nasogastric (NG) tubes

• These are tubes used to intubate the stomach.

• The tube is inserted from the nose to the stomach.

Purpose
• To decompress the stomach by removing fluids or gas to promote
abdominal comfort
• To allow surgical anastomoses to heal without distention
• To decrease the risk of aspiration
• To administer medications to clients who are unable to swallow
• To provide nutrition by acting as a temporary feeding tube
• To irrigate the stomach & remove toxic substances, such as in poisoning
• To maintain gut integrity & help prevent stress ulcer by initiating early
feeding in critically ill clients
• Ans: 2
 Types of tubes
1. Levin tube: Single-lumen NG tube. Used to remove gastric contents
via intermittent suction or to provide tube feedings

2. Salem sump tube: double-lumen NG tube with an air vent (pigtail) for
decompression with intermittent continuous suction
• Continuous suction can be applied to decompress the stomach
• Larger lumen is attached to suction & the smaller lumen (within the
larger one) is open to the atmosphere.
Air vent
• not to be clamped, must remain open as it provides continuous flow of
atmospheric air to prevent excessive suction force & prevent damage to
the gastric mucosa
• Always kept above the level of the stomach to prevent reflux
• If leakage occurs, instill 30 mL of air into the air vent and irrigate the
main lumen with normal saline (NS).
Levin Salem sump tube
 Intubation procedure

• Follow agency procedures.

• Explain the procedure and its potential discomfort to the client.
• Position the client in a high-Fowler’s position with pillows behind
the shoulders.
• Determine which nostril is more patent.
• Measure the length of the tube from the bridge of the nose to
the earlobe to the xiphoid process and indicate this length with a
piece of tape on the tube
(remember the abbreviation NEX, which stands for nose, earlobe &
xiphoid process)
• If the client is conscious and alert, have him or her swallow or
drink water (follow agency procedure)
• Lubricate the tip of the tube with water-soluble lubricant.
• Gently insert the tube into the nasopharynx and advance the
tube.
• have the client first tilt his head back for insertion into the nostril,
then to flex his neck forward and swallow
• The tip should instead be directed parallel to the floor, directly
toward the back of the patient's throat.
• When the tube nears the back of the throat (first black
measurement on the tube), instruct the client to swallow or drink
sips of water (unless contraindicated).
• If resistance is met, slowly rotate and aim the tube downward
and toward the closer ear
• In the intubated or semiconscious client, flex the head toward
the chest while passing the tube.
• Immediately withdraw the tube slightly if any change is noted in
the client’s respiratory status. Stop the tubing advancement, and
wait until the distress subsides.
• Following insertion, obtain an abdominal x-ray study to
confirm placement of the tube.
• Connect the tube to suction (intermittent or continuous) as
prescribed if the purpose of the tube is for decompression.
• Secure the tube to client’s nose with adhesive tape and to the
client’s gown (follow agency procedure and check for client
allergy to tape).
A nurse is inserting a nasogastric tube in an adult male client. During
the procedure, the client begins to cough and has difficulty
breathing. Which of the following is the appropriate nursing action?
A. Quickly insert the tube
B. Notify the physician immediately
C. Remove the tube and reinsert when the respiratory distress
subsides
D. Pull back on the tube and wait until the respiratory distress
subsides

Ans: D
The client has orders for a nasogastric (NG) tube insertion.
During the procedure, instructions that will assist in the insertion
would be:
A. Instruct the client to tilt his head back for insertion in the
nostril, then flex his neck for the final insertion.
B. After insertion into the nostril, instruct the client to extend
his neck.
C. Introduce the tube with the client’s head tilted back, then
instruct him to keep his head upright for final insertion.
D. Instruct the client to hold his chin down, then back for
insertion of the tube.

Ans: A
 Post procedure care
• Place the client in semi-fowler’s position to help keep the tube
from lying against the stomach wall, to prevent gastric reflux
• Observe the client for nausea, vomiting, abdominal fullness, or
distention and monitor gastric output.
• Check residual volumes every 4 hours, before each feeding, and
before giving medications.
• Aspirate all stomach contents (residual) & measure the amount.
• Reinstill residual contents to prevent excessive fluid and
electrolyte losses, unless the residual contents appear abnormal
or the volume is large (greater than 250 mL).
• Withhold a feeding if the residual amount is more than 100 mL or
according to agency or nutritional consult recommendations.
• Inspect drainage system for patency (eg. tubing kink or blockage)
• Before the instillation of any substance through the tube (i.e.,
irrigation solution, feeding, medications), aspirate stomach
contents and test the pH (a pH of 3.5 or lower indicates that the
tip of the tube is in a gastric location).
• On a daily basis, remove adhesive tape that is securing the tube
to the nose & clean and dry the skin, assessing for excoriation;
then reapply the tape.
• Provide mouth care every 4 hours as this helps to maintain
moisture of oral mucosa & promote client comfort
• Turn off suction briefly during auscultation as the suction sound
can be mistaken for bowel sounds
Reducing risk for aspiration
• Ans: 1,3
Nurse Oliver checks for residual before administering a bolus tube
feeding to a client with a nasogastric tube and obtains a residual
amount of 150 mL. What is the appropriate action for nurse to take?
A. Hold the feeding
B. Reinstill the amount and continue with administering the feeding
C. Elevate the client’s head at least 45 degrees and administer the
feeding
D. Discard the residual amount and proceed with administering the
feeding

Ans: A
Jason, a 22 y.o. accident victim, requires an NG tube for feeding.
What should you immediately do after inserting an NG tube for
liquid enteral feedings?
A. Aspirate for gastric secretions with a syringe.
B. Begin feeding slowly to prevent cramping.
C. Get an X-ray of the tip of the tube within 24 hours.
D. Clamp off the tube until the feedings begin.

Ans: A
Nurse Ryan is assessing for correct placement of a nasogastric tube.
The nurse aspirates the stomach contents and checks the contents
for pH. The nurse verifies correct tube placement if which pH value
is noted?
A. 3.5
B. 7.0
C. 7.35
D. 7.5

Ans: A
Ans: 1,3,4,5
 Gastrostomy or jejunostomy tubes
• surgically inserted
• A dressing is placed at the site of insertion.
• The dressing needs to be removed, the skin needs to be cleansed
(with a solution determined by PHCP or agency procedure), and a
new sterile dressing needs to be applied every 8 hours (or as
specified by agency policy).
• The skin at the insertion site is checked for signs of excoriation,
infection, or other abnormalities, such as leakage of the feeding
solution.
 Percutaneous endoscopic Gastrostromy (PEG)

• The tube tract begins to mature in 1 to 2 weeks & is not fully

established until 4 to 6 weeks
• If dislodgement occurs before 1 week, when it is immature,
notify the HCP who will replace the tube either surgically or
endoscopic.
• Do not try to reinsert because it can cause peritonitis or sepsis if
the tube remains within the peritoneum

• If dislodgement occur after the tube matures, the insertion of a

Foley's catheter or reinsertion of the tube should be attempted.
• Ans: 3
 Irrigation

• Assess placement before irrigating

• use NS solution (check agency procedure).
• Observe the client for fluid and electrolyte balance.
• Perform irrigation every 4 hours to assess and maintain the
patency of the tube.
• Gently instill 30 to 50 mL of NS (depending on agency policy) with
an irrigation syringe.
• Pull back on the syringe plunger to withdraw the fluid to check
patency; repeat if the tube flow is sluggish.
 Removal of a nasogastric tube

• verify physician orders

• If the NG tube was ordered to remove gastric content, the physician’s
order may state to “trial” clamping the tube for a number of hours to
see if the patient tolerates its removal.
• During the trial, the patient should not experience any nausea,
vomiting, or abdominal distension.
• Ask the client to take a deep breath and hold it. This will close the
epiglottis
• Kink the NG tube near the nares & remove the tube with one smooth,
continuous pull.
• Remove the tube slowly and evenly over the course of 3 to 6 seconds
• Coil the tube around the hand while removing it.
A nurse is preparing to remove a nasogastric tube from a female
client. The nurse should instruct the client to do which of the
following just before the nurse removes the tube?
A. Exhale
B. Inhale and exhale quickly
C. Take and hold a deep breath
D. Perform a Valsalva maneuver

Ans: C
 Gastrointestinal tube feedings

Types of administration
a. Bolus: A bolus resembles normal meal feeding patterns; formula
is administrated over a 30- to 60-minute period every 3 to 6
hours; the amount of formula and frequency can be
recommended by the dietitian and is prescribed by the PHCP.

b. Continuous: Feeding is administered continually for 24 hours; an

infusion feeding pump regulates the flow.

c. Cyclical: Feeding is administered in the daytime or nighttime for

approximately 8 to 16 hours (feedings at night allow for more
freedom during the day). An infusion feeding pump regulates
the flow.
 Administration of feedings

• Assess bowel sounds; hold the feeding and notify the PHCP if bowel
sounds are absent.
• Position the client in a high-Fowler’s position; if comatose, place in
highFowler’s and on the right side.
• Assess tube placement by aspirating gastric contents and measuring
the pH (should be 3.5 or lower)
• Check residual amounts; usually, if the residual is less than 100 mL,
feeding is administered
• Large-volume aspirates indicate delayed gastric emptying and place the
client at risk for aspiration.
• Aspirate all stomach contents (residual), measure the amount, and
return the contents to the stomach to prevent electrolyte imbalances
(unless the color or characteristics of the residual is abnormal or the
amount is greater than 250 mL).
• Warm the feeding to room temperature to prevent diarrhea and
cramps.
• Use an infusion feeding pump for continuous or cyclic feedings.
• For bolus feeding, maintain the client in a high-Fowler’s position
for 30 minutes after the feeding.
• Use an infusion pump or allow the feeding to infuse via gravity.
• Do not plunge the feeding into the stomach.
• For a continuous feeding, keep the client in a semi-Fowler’s
position at all times.
A client has a percutaneous endoscopic gastrostomy tube
inserted for tube feedings. Before starting a continuous feeding,
the nurse should place the client in which position?
A. Semi-Fowlers
B. Supine
C. Reverse Trendelenburg
D. High Fowler’s

Ans: A
 Precautions
• Always assess the placement of a gastrointestinal tube before instilling
feeding solutions, medications, or any other solution
• Change the feeding container/bag and tubing every 24 hours or per
agency policy.
• Food (formula) should not be left in the bag for more than 4 hours. Do
not hang more solution than is required for a 4-hour period; this
prevents bacterial growth.
• Check the expiration date on the formula before administering.
• Shake formula well before pouring it into container (feeding bag).
• Some feedings require use of bag in which formula is added, or use of
bottles that feeding tubing can be attached to directly.
• The tubing sometimes has a Y-site connection so a regular flush can be
programmed using pump rather than a piston syringe.
• Always assess bowel sounds; do not administer any feedings if bowel
sounds are absent.
• Administer the feeding at the prescribed rate or via gravity flow
(intermittent bolus feedings) with a 50- to 60-mL syringe with the
plunger removed.
• Gently flush with 30 to 50 mL of water or NS (depending on
agency policy) using the irrigation syringe after the feeding.

Complications of feedings
• aspiration, diarrhea, vomiting, a clogged tube, tube displacement,
hyperglycemia, abdominal distention

Diarrhea
• Assess the client for lactose intolerance.
• Use fiber-containing feedings.
• Administer feeding slowly and at room temperature.
Aspiration
• If aspiration occurs, suction as needed
• Assess respiratory rate, auscultate lung sounds, monitor
temperature for aspiration pneumonia, and prepare to obtain a
chest radiograph.
Prevention of aspiration
• Verify tube placement.
• Do not administer the feeding if residual is more than 100 mL
• Keep the head of the bed elevated.

Clogged tube
• Use liquid forms of medication, if possible.
• Flush the tube with 30 to 50 mL of warm water or NS (depending
on agency policy) before and after medication administration and
before and after bolus feeding.
• Flush with water every 4 hours for continuous feeding.
Vomiting
• If the client vomits, stop the tube feeding and place the client in
a side-lying position; suction the client as needed.
• Administer antiemetics as prescribed.

Prevention of vomiting
• Administer feedings slowly and, for bolus feedings, make feeding
last for at least 30 minutes.
• Measure abdominal girth.
• Do not allow the feeding bag to empty.
• Do not allow air to enter the tubing.
• Administer the feeding at room temperature.
• Elevate the head of the bed.
Which of the following nursing interventions should the nurse
perform for a female client receiving enteral feedings through a
gastrostomy tube?
A. Change the tube feeding solutions and tubing at least every 24
hours.
B. Maintain the head of the bed at a 15-degree elevation
continuously.
C. Check the gastrostomy tube for position every 2 days.
D. Maintain the client on bed rest during the feedings.

Ans: A
While a female client is being prepared for discharge, the
nasogastric (NG) feeding tube becomes clogged. To remedy this
problem and teach the client’s family how to deal with it at
home, what should the nurse do?
A. Irrigate the tube with warm water.
B. Advance the tube into the intestine.
C. Apply intermittent suction to the tube.
D. Withdraw the obstruction with a 30-ml syringe.

Ans: A
 Administering Medications via a Nasogastric,
Gastrostomy, or Jejunostomy Tube

• Check the primary health care provider’s (PHCP’s) prescription.

• Prepare the medication for administration.
• Ensure that medication prescribed can be crushed or is a capsule
that can be opened; use elixir forms of medications if available.
• Dissolve crushed medication or capsule contents in 15 to 30 mL of
water.
• Verify the client’s identity (2 identifiers) and explain the
procedure to the client.
• Don gloves; check tube placement and residual contents before
instilling the medication; check for bowel sounds.
• Flush with 30 to 50 mL of water or normal saline (NS), depending
on agency policy.
• Pinch off tubing and attach an irrigation syringe to the nasogastric
tube and pour the medication into the syringe.
• Release the pinch on the tubing immediately and allow
medication to infuse via gravity.
• Flush with 30 to 50 mL of water or normal saline (NS) at the end
as well, depending on agency policy.
• If more than one medication is prescribed, flush 10 ml of water
between medications
• Clamp the tube for 30 to 60 minutes after medication
administration, depending on medication and agency policy.
• If the medication is to be given on an empty stomach, the enteral
feeding may need to be stopped from 30 minutes before until 30
minutes after the medication is given
• Document the administration of the medication and any other
appropriate information.
Nurse Joy is preparing to administer medication through a
nasogastric tube that is connected to suction. To administer the
medication, the nurse would:
A. Position the client supine to assist in medication absorption
B. Aspirate the nasogastric tube after medication administration to
maintain patency
C. Clamp the nasogastric tube for 30 minutes following
administration of the medication
D. Change the suction setting to low intermittent suction for 30
minutes after medication administration

Ans: C
 Intestinal tubes

• The intestinal tube is passed nasally into the small intestine.

• It may be used to decompress the bowel or to remove accumulated
intestinal secretions when other interventions to decompress the bowel
are not effective.
• The tube enters the small intestine through the pyloric sphincter
because of the weight of a small bag containing tungsten at the end.
• Tungsten is injected with a needle (21G or smaller) & syringe into the
bag of the tube once it is in the stomach

Types of tubes include

• Cantor tube (single lumen)
• Miller-Abbott tube (double lumen): one lumen leads to balloon &
second is for irrigation & drainage
 Cantor tube
Levin tube

Salem sump
tube

Miller- Abbott
tube

Sengstaken-Blakemore tube
 Interventions

• Assess the PHCP’s prescriptions and agency policy for advancement and
removal of the tube and tungsten.
• Position the client on the right side to facilitate passage of the weighted
bag in the tube through the pylorus of the stomach and into the small
intestine.
• Assess the abdomen during the procedure by monitoring drainage from
the tube and the abdominal girth.
• Do not secure the tube to the face with tape until it has reached final
placement (may take several hours) in the intestines.
• If the tube becomes blocked, notify the PHCP.
• To remove the tube, the tungsten is removed from the balloon portion
of the tube with a syringe
• The tube is removed gradually (6 inches [15 cm] every hour) as
prescribed by the PHCP.
 Esophageal and gastric tubes (Balloon
Tamponade tube)

• Indication: Used temporarily to control bleeding from esophageal

varices. It applies pressure against bleeding esophageal veins to
control the bleeding when other interventions are not effective or
they are contraindicated.

• Contraindications: ulceration or necrosis of the esophagus or has

had previous esophageal surgery because of the risk of rupture.
 Types of tubes

1. The Sengstaken-Blakemore tube: contains 2 balloons & 3 lumens.

• used only occasionally,
• Contains triple-lumen gastric tube with an inflatable esophageal
balloon (compresses esophageal varices), an inflatable gastric
balloon (applies pressure at the cardioesophageal junction), and a
gastric aspiration lumen (cooneted to low suction).
• A nasogastric tube also is inserted in the opposite naris to collect
secretions that accumulate above the esophageal balloon.

2. Minnesota tube: modified SengstakenBlakemore tube with an

additional lumen (a 4-lumen gastric tube) for aspirating
esophagopharyngeal secretions.
 Interventions

• Check patency and integrity of all balloons before insertion.

• Label each lumen.
• Place the client in the upright or Fowler’s position for insertion.
• Immediately after insertion, prepare for radiograph of the upper
abdomen & chest to verify placement.
• Maintain head elevation once the tube is in place.
• A weight is attached to the external end of tube to provide
tension & hold the gastric balloon securely in place below
esophageal sphincter.
• Double-clamp the balloon ports to prevent air leaks.
• Airway obstruction can occur if the balloon tamponade tube
becomes dislodged & the balloon migrates into the oropharynx
• Keep scissors at the bedside at all times; monitor for respiratory
distress, and if it occurs, cut the tubes to deflate the balloons.
• To prevent ulceration or necrosis of esophagus, release
esophageal pressure at intervals as prescribed & per agency
policy.
• Also monitor for aspiration
• Monitor for increased bloody drainage, which may indicate
persistent bleeding and rupture of the varices.
• Monitor for signs of esophageal rupture: drop in blood pressure,
increased heart rate, and back and upper abdominal pain.
• Esophageal rupture is an emergency, and signs of esophageal
rupture must be reported to the PHCP immediately.
The nurse must be alert for complications with Sengstaken-
Blakemore intubation including:
A. Pulmonary obstruction
B. Pericardiectomy syndrome
C. Pulmonary embolization
D. Cor pulmonale

Ans: A
• Ans: 2
Which rationale supports explaining the placement of an esophageal
tamponade tube in a client who is hemorrhaging?
A. Allowing the client to help insert the tube
B. Beginning teaching for home care
C. Maintaining the client's level of anxiety and alertness
D. Obtaining cooperation and reducing fear

Ans: D An esophageal tamponade tube would be inserted in critical

situations. Typically, the client is fearful and highly anxious. The
nurse, therefore, explains the placement to help obtain the client's
cooperation and reduce his fear.
 Lavage tubes

• Used to remove toxic substances from the stomach

Types of tubes
a. Lavacuator: The Lavacuator is an orogastric tube with a large
suction lumen and a smaller lavage–vent lumen that provides
continuous suction; irrigation solution enters the lavage lumen
while stomach contents are removed through the suction lumen.

b. Ewald tube: A single-lumen large tube used for rapid 1-time

irrigation and evacuation
 Parenteral Nutrition (PN)

• Parenteral nutrition supplies nutrients via the veins.

• PN consists of both partial parenteral nutrition (PPN) and total
parenteral nutrition (TPN).
• The indication of the type used depends on the client’s nutritional
needs.
• PN supplies carbohydrates in the form of dextrose, fats in an
emulsified form, proteins in the form of amino acids, vitamins,
minerals, electrolytes, and water.
• PN prevents subcutaneous fat and muscle protein from being
catabolized by the body for energy.
• PN solutions are hypertonic due to the higher concentrations of
glucose and addition of amino acids.
 Indications

• Clients with severely dysfunctional or nonfunctional

gastrointestinal tracts who are unable to process nutrients
• Clients who can take some oral nutrition but not enough to meet
their nutrient requirements may benefit from PN.
• Clients with multiple gastrointestinal surgeries, gastrointestinal
trauma, severe intolerance to enteral feedings, or intestinal
obstructions, or who need to rest the bowel for healing
• Clients with severe nutritionally deficient conditions such as AIDs,
cancer, burn injuries, or malnutrition, or clients receiving
chemotherapy,
• When there is no other nutritional alternative.

Note: Administering nutrition orally or through a nasogastric tube

is usually initiated first, before PN is initiated
Stephanie, a 28 y.o. accident victim, requires TPN. The rationale
for TPN is to provide:
A. Necessary fluids and electrolytes to the body.
B. Complete nutrition by the I.V. route.
C. Tube feedings for nutritional supplementation.
D. Dietary supplementation with liquid protein given between
meals.

Ans: B
Your patient has a GI tract that is functioning, but has the
inability to swallow foods. Which is the preferred method of
feeding for your patient?
A. TPN
B. PPN
C. NG feeding
D. Oral liquid supplements

Ans: C
 Administration of PN

• PPN: Usually administered through a large distal vein in arm with

a standard peripheral IV catheter or midline or through a PICC.
• A midline is placed in an upper arm vein such as brachial or
cephalic vein with tip ending below the level of the axillary line.
• If a PICC cannot be established, the subclavian vein or internal or
external jugular veins can be used for PPN.

• TPN: Administered through a central vein; PICC is acceptable.

• Common sites: subclavian vein, internal or external jugular vein.
• If the bag of intravenous solution (PN) is empty and the nurse is
waiting for the delivery of a new bag
• A 10% dextrose in water solution should be infused at the
prescribed rate to prevent hypoglycemia
• The prescribed solution should be obtained as soon as possible.

• The delivery of hypertonic solutions into peripheral veins can

cause sclerosis, phlebitis, or swelling.
• Monitor closely for these complications.
• Ans: 2
 Components of parenteral nutrition

• Carbohydrates: The strength of the dextrose solution depends on

the client’s nutritional needs
• The route of administration (central or peripheral), and agency
protocols
• Carbohydrates typically provide 60% to 70% of calorie (energy)
needs.

• Amino acids (protein): Concentrations range from 3.5% to 20%.

• Lower concentrations are most commonly used for peripheral
vein administration
• Higher concentrations are most often administered through a
central vein
• About 15% to 20% of total energy needs should come from
protein.
 Fat emulsion (lipids)

• Lipids provide up to 30% of calorie (energy) needs.

• Lipids provide non-protein calories and prevent or correct fatty
acid deficiency.
• Lipid solutions are isotonic and therefore can be administered
through a peripheral or central vein
• The solution may be administered through a separate IV line
below the filter of the main IV administration set by a Yconnector,
or as an admixture to the PN solution (3-in-1 admixture consisting
of dextrose, amino acids, and lipids).
• Most fat emulsions are prepared from soybean or safflower oil,
with egg yolk to provide emulsification
• The primary components are linoleic, oleic, palmitic, linolenic,
and stearic acids (assess the client for allergies).
• Glucose-intolerant clients or DM: benefit from receiving a larger
percentage of their PN from lipids, helps control blood glucose levels
and lower insulin requirements caused by infused dextrose.
• Examine the bottle for separation of emulsion into layers or fat
globules or for the accumulation of froth; if observed, do not use and
return the solution to the pharmacy.
• Additives should not be put into the fat emulsion solution.
• Usually a 1.2-µm filter or larger should be used, because the lipid
particles are too large to pass through a 0.22-µm filter.
• Infuse solution at the flow rate prescribed—usually slowly at 1
mL/minute initially—monitor vital signs every 10 minutes, and observe
for adverse reactions for the first 30 minutes of the infusion.
• If signs of adverse reaction occur, stop the infusion and notify the PHCP
• If no adverse reaction occurs, adjust the flow rate to prescribed rate.
• Monitor serum lipids 4 hours after discontinuing the infusion.
• Fat emulsions (lipids) contain egg yolk phospholipids and should not be
given to clients with egg allergies.
 Signs and Symptoms of an Adverse Reaction to Lipids

• Chest and back pain

• Fever, Chills
• Cyanosis
• Diaphoresis
• Dyspnea
• Flushing
• Headache
• Nausea and vomiting
• Pressure over the eyes
• Thrombophlebitis
• Vertigo
 Other components

• Standard multivitamin preparation to meet most vitamin needs and

prevent deficiencies.
• Individual vitamin preparations added, as needed & as prescribed.
• Minerals and trace elements: available in various concentrations to
promote normal metabolism.
• Electrolytes: requirements depends on body weight, presence of
malnutrition or catabolism, degree of electrolyte depletion, changes in
organ function, electrolyte losses, disease process.
• Water: The amount of water needed in a PN solution is determined by
electrolyte balance and fluid requirements.
• Regular insulin: May be added to control the blood glucose level
because of the high concentration of glucose in the PN solution.
• Heparin: May be added to reduce buildup of a fibrinous clot at the
catheter tip.
 Administration

1. Continuous PN
• Infused continuously over 24 hours
• Most commonly used in a hospital setting

2. Intermittent or cyclic PN
• In general, the nutrient solution infusion regimen varies and is
commonly administered overnight.
• Allows clients requiring PN on a long-term basis to participate in
activities of daily living during the day without the inconvenience
of an IV bag and pump set.
• Monitor glucose levels closely because of the risk of
hypoglycemia due to lack of glucose during non-infusion times.
 Discontinuing PN therapy

• Evaluation of nutritional status by a nutritionist is done before PN

is discontinued.
• If discontinuation is prescribed, gradually decrease the flow rate
for 1 to 2 hours while increasing oral intake
• Abrupt discontinuation can result in hypoglycemia.
• Then TPN is replaced with a solution containing dextrose
• Check the level 1 hour after discontinuing the PN & monitor
glucose levels regularly thereafter
• After removal of the IV catheter, change the dressing daily until
the insertion site heals.
• Encourage oral nutrition.
• Record oral intake, body weight, and laboratory results of serum
electrolyte and glucose levels.
 Complications

• Pneumothorax and air embolism are associated with central

line placement
• Air embolism is also associated with tubing changes.

• Other complications include infection (catheter-related),

hypervolemia, and metabolic alterations such as
hyperglycemia and hypoglycemia; these complications are
usually caused by the PN solution itself
 Air embolism

• Causes: catheter system open or IV tubing disconnected, air entry

on IV tubing changes

• S/S: apprehension, chest pain, dyspnea, hypotension, loud

churning sound heard over pericardium on auscultation, rapid
weak pulse, respiratory distress

Interventions
• Clamp all ports of the IV catheter
• Place the client in a left side lying position with the HOB lower
than feet
• Notify the HCP
• Administer oxygen
 Prevention of air embolism

• make sure all catheter connections are secure (use tape per agency
protocols)
• Clamp the catheter when not in use & when changing caps
• Instruct the client in the Valsalva maneuver for tubing & cap
changes. The client should hold their breath & bear down
• For tubing & cap changes, place the client in the Trendelenburg’s
position (if not contraindicated) with the head turned to the
opposite direction of the insertion site.
 Central Venous Catheter Site with a Suspected Infection

• Causes: poor aseptic technique, catheter contamination, contamination

of solution

• S/S: chills, fever, elevated WBC count, redness or drainage at insertion

site

Interventions
• Notify the primary health care provider (PHCP).
• Prepare to remove the catheter and for possible restart at a different
location.
• Remove the tip of the catheter and send it to the laboratory for culture
if prescribed by the PHCP.
• Prepare the client for obtaining blood cultures.
• Prepare for antibiotic administration..
 Hyperglycemia

• Possible cause: high concentration of dextrose in solution,

Receiving solution too quickly, Not enough insulin, Infection,
steroids, low tolerance for dextrose in critically ill clients due to
inflammatory response resulting in production of
counterregulatory hormones

• Signs & symptoms: Restlessness, confusion, weakness,

diaphoresis, elevated glucose > 200 mg/dl, excessive thirst,
fatigue, Kussmaul respirations, coma (when severe)
 Interventions foe hyperglycemia

• Monitor blood glucose levels to confirm first

• The infusion rate may need to be slowed
• Notify the PHCP
• Administer regular insulin as prescribed
• Reducing amount of carbohydrate in the TPN solution
• Monitor blood glucose levels at regular intervals
• Assess for history of glucose intolerance
• Assess for medication history (corticosteroids, increase blood
glucose)
• Use strict aseptic technique to prevent infection
• Ans: 2
 Additional nursing considerations

• Check the PN solution with the PHCP’s prescription to ensure that the
prescribed components are contained in the solution
• Some health care agencies require validation of the prescription by 2
registered nurses.
• To prevent infection and solution incompatibility, IV medications and
blood are not given through the PN line.
• Blood for testing may be drawn from the central venous access site; a
port other than the port used to infuse the PN is used for blood draws
after the PN has been stopped for several minutes (per agency
procedure), because the PN solution can alter the results of the sample.
• The client with a central venous access site receiving PN should still
have a venipuncture site.
• Monitor partial thromboplastin time and prothrombin time for clients
receiving anticoagulants.
• Monitor electrolyte and albumin levels and liver and renal function
studies, as well as any other prescribed laboratory studies.
• Blood studies for blood chemistries are normally done every other day
or 3 times per week (per agency procedures) when the client is
receiving PN; the results are the basis for the PHCP continuing or
changing the PN solution or rate.
• Monitor blood glucose levels as prescribed (usually every 4 hours)
because of the risk for hyperglycemia from the PN solution
components.
• In severely dehydrated clients, the albumin level may drop initially after
initiating PN because the treatment restores hydration.

• PN solutions should be stored under refrigeration and administered

within 24 hours from the time they are prepared (remove from
refrigerator 0.5 to 1 hour before use).
• PN solutions that are cloudy or darkened should not be used and
should be returned to the pharmacy.
• With severely malnourished clients, monitor for “refeeding syndrome”
(a rapid drop in potassium, magnesium, and phosphate serum levels).
• The electrolyte shift that occurs in “refeeding syndrome” can cause
cardiovascular, respiratory, and neurological problems
• Monitor for shallow respirations, confusion, weakness, bleeding
tendencies, and seizures.
• If noted, the PHCP is notified immediately.

• Abnormal liver function values may indicate intolerance to or an excess

of fat emulsion or problems with metabolism with glucose and protein.
• Abnormal renal function tests may indicate an excess of amino acids.

• Additions of substances such as nutrients to PN solutions should be

made in the pharmacy and not on the nursing unit.
• Consultation with the nutritionist should be done on a regular basis (as
prescribed or per agency protocol).
 Home care instructions
• Teach the client and caregiver how to obtain, administer, and
maintain parenteral nutrition fluids.
• Teach the client and caregiver how to change a sterile dressing.
• Obtain a daily weight at the same time of day in the same clothes.
• Stress that if a weight gain of more than 3 lb/week is noted, this
may indicate excessive fluid intake and should be reported.
• Monitor the blood glucose level and report abnormalities
immediately.
• Teach the client how to monitor for and manage hypoglycemia
and hyperglycemia.
• Teach the client and caregiver about the signs and symptoms of
side effects or adverse effects such as infection, thrombosis, air
embolism, and catheter displacement.
• Teach the client and caregiver the actions to take if a complication
arises and about the importance of reporting complications to the
primary health care provider.
• For signs and symptoms of thrombosis, the client should report
edema of the arm or at the catheter insertion site, neck pain, and
jugular vein distention.
• Leaking of fluid from the insertion site or pain or discomfort as the
fluids are infused may indicate displacement of the catheter; this
must be reported immediately.
• Inform the client and caregiver about the importance of follow-up
care.
• Teach the client to keep electronic infusion devices fully charged in
case of electrical power failure.