AUTHOR : SUMANA BISTA
Tube Feeding (Gastric Gavage)
Gavage (gastric) feeding is an artificial method of giving fluids and nutrients through a tube, that has passed into the oesophagus and stomach through the nose, mouth or through the opening made on the abdominal wall, when oral intake is inadequate or impossible.
Indications for Tube Feeding
1. When the client is unable to take food by mouth. For example, unconscious, semiconscious and delirious clients.
2. For a client who refuses food. E.g. client with psychosis.
3. When condition of mouth or oesophagus make the swallowing difficult or impossible. For example, fracture of the jaw, repair of the cleft palate and cleft lips, surgery of the mouth, throat and oesophagus, paralysis of face and throat, stricture of the oesophagus.
4. When the client is too weak to swallow food or when the conditions make it difficult to take a large amount of food orally, e.g., acute and chronic infections, severe burns, terminal malignancy, malnutrition and prematurity.
5. When the client is unable to retain the food, e.g. anorexia nervosa and vomiting.
Advantages of Tube Feeding
1. An adequate amount of all types of nutrients including distasteful foods and medications can be supplied.
2. Large amount of fluids can be given with safety.
3. The dangers of a parenteral feeding (e.g. venous thrombosis) are avoided.
4. Tube feeding may be continued for weeks without any danger to the client.
5. The stomach may be aspirated at any time if desired.
6. Overloading of the stomach can be prevented by a drip method.
Principle Involved in Gastric Gavage
1. Tube feeding is a process of giving liquid nutrients or medications through a tube into the stomach when the oral intake is inadequate or impossible.
Action and Explanation: feeding can be given with a nasogastric tube – a tube that is passed through the nose and oesophagus; so that the food may reach the stomach and it is called oesophageal feeding.
Feeding can be given with a gastrostomy tube – giving liquid diet through a tube or catheter which is introduced into the stomach through the abdominal wall and is called gastrostomy feeding (gastros – stomach, ostomy – making an opening into)
2. A thorough knowledge of the anatomy and physiology of the digestive tract and respiratory tract, ensures safe induction of the tube (avoid misplacement of the tube).
Action and explanation – there are many pouches in the respiratory and digestive tract where the tube may remain kinked. E.g. nasal cavity, oral cavity etc. therefore, it is necessary to pass the tube along the curve of the digestive tract.
As trachea is in front of the oesophagus, it has got every chance of the tube to enter into the trachea and cause asphyxia in the client. Therefore, the nurse should know the sign of the correct placement of the tube.
The mucus membrane lines the digestive tract and it can be injured by friction when the tube is passed carelessly or without proper lubrication.
The length of the tube that is introduced should correspond to the length of the digestive tract extending from the digestive tract extending from the nostrils to the stomach which can be measured by the distance taken from the bridge of the nose to the ear lobe plus the distance from the ear lobe to the tip of the xiphoid process of the sternum. It is about 10 to 12 inches.
The stomach is never completely empty, it contains some gastric juice. Aspiration of the fluid through the tube indicates the presence of the tube in the stomach and not in the trachea.
3. Microorganisms enter the body through food and drink.
Action and explanation – all equipment used for feeding should be clean. Separate articles may be kept for individual clients to prevent cross infection.
Many organisms enter the body through the food and drink. The food has to be prepared, handled and stored under good hygienic conditions. The unused feeds if any, has to be stored in refrigerators to prevent multiplication of bacteria.
The nurse should wash her hands thoroughly before preparing the feeds and feeding the client.
The clients who are receiving tube feeding need frequent mouth care.
The tube that is lying outside the nostrils needs cleaning to prevent the entry of bacteria into the gastrointestinal tract.
4. Introduction of the tube into the mouth or nostrils is a frightening situation and the client will resist every attempt. Mental and physical preparation of the client facilitates introduction of the tube.
Action and explanation – explain the procedure to the client to win the confidence and cooperation. It will help the client to check the cough reflex when the tube reaches the pharynx. Swallowing the saliva on command facilitates the downward movement of the tube.
Explaining the sequence of the procedure and the reassurance will remove the fear. Remember “uncertainty builds up anxiety and knowledge dispels the fear”.
Placing the client in a Fowler’s position or in a sitting position with the head inclined forward facilitates downward movement of the tube along the curve of the digestive tract.
5. Systematic ways of working adds to the comfort and safety of the client and help in the economy of material, time and energy.
Action and explanation – place the client in a comfortable position. Adjust the height of the bed to the comfortable working of the nurse.
Check the tube for kinks and patency.
Prepare the client physically and mentally for the tube feeding.
Assemble and arrange articles conveniently before starting the procedure.
Protect the personal clothing and the bedliner.
Before introducing the rubber tube, soak it in ice water to make it stiff. Apply lubricant for the easy insertion of the tube. Insert the tube gently but quickly in a backward and downward direction. Do not use any force.
Do not use excessive amount of oil for lubrication. Use only a small quantity. Any oil dribbled into the respiratory tract will not be absorbed and it will act as a foreign body.
Every time before giving the feed, make sure that the tube is in the stomach.
Rinse the tube with plain water at the end of the feeding to wash of any feed left in the tube.
Accurate recording of the intake of food will prevent under nutrition and malnutrition.
While removing the tube, pinch the tube and pull it out gently and quickly so that the fluid may not trickle down the trachea.
Strain the feed to prevent blocking of the tube.
Regulate the flow of the feed by adjusting the height of the funnel and the diameter of the tube.
1. Tube feeding is given only by a doctor’s order.
2. If the client is conscious, explain the procedure and reassure the client to win his confidence and cooperation.
3. Remove the denatures if any, to prevent it from dislodging and blocking the respiratory tract.
4. A rubber tube may be placed in a bowl of ice to cool and stiffen.
5. Lubricate the tube with a suitable lubricant preferably with a water soluble jelly. If mineral oils (glycerin, liquid paraffin) are used, it should be applied to the tube to the minimum with a paper square. A drop of mineral oil, if dropped into the respiratory passage acts as a foreign body because it is not absorbed by the lung tissue.
6. If the tube is dipped in a liquid or lubricant before the insertion, make sure that the blind end is not left filled with the fluid or lubricant, because this may drop into the larynx and strangulate the client.
7. All equipment used for feeding should be clean. The food has to be prepared, handled and stored under “hygienic conditions” because many organisms enter the body through the food and drink.
8. Every time before giving the feed, make sure that the tube is in the stomach by aspirating a small quantity of (5 to 10 ml) stomach contents.
9. While removing the tube, pinch the tube and pull it out gently and quickly so that the fluid may not trickle down the trachea.
10, During the introduction of the tube, never use force as it may cause injury to the mucus membrane.
11. Avoid introducing air into the stomach during each food. Expel the air from the tube by lowering the tube below the level of the stomach. Pinch the tube before the fluid run into the stomach completely from the tube.
12. Restraints used if any, should be limited to the minimum. For infants and irrational clients, some form of restraints may be necessary, but they should not feel that they are punished.
13. Feedings may be given at intervals of 2, 3 or 4 hours and the amount is not exceeding 150 to 300 ml per feed. The total amount in 24 hours varies between 2000 and 3000 ml. if drip method is used, the speed of flow should not exceed nausea, regurgitation and excessive peristalsis usually associated with too much and too rapid administration.
14. Intake and output is recorded accurately.
15. Watch for complications such as nausea, vomiting, distension, diarrhea, aspiration pneumonia, asphyxia, fever, water and electrolyte imbalance. The water and electrolyte imbalance may be reflected in changes in the skin, thirst, vital signs, intake and output, level of consciousness, body weight, moisture of the mucus membrane and serum analysis. If the dehydration is not corrected, it may result in high fever, disorientation, drying of the mucus membrane etc.
16. Clients receiving tube feeding should receive frequent mouth care to prevent complications of a neglected mouth.
Nurse’s Responsibility in Administering a Tube Feeding
1. Identify the client with name, bed no., O.P. No., etc.
2. Check the doctor’s orders for any specific precautions if any, regarding the tube feeding, movement of the client, positioning of the client etc.
3. Check the level of consciousness and the ability to follow directions.
4. Check the ability for self care, ability to move and to maintain a desired position during the insertion of the tube.
5. Check whether the feed is ready at hand.
6. Check the articles available in the client’s unit.
Preparation of Articles
A tray containing:
Feeding cup with water.
Purpose: to give mouthwash before and after the feed.
Mackintosh and towel.
Purpose: to protect the garments and bed linen.
Cotton tipped applicators
Saline or sodadicarb solution
Levine tube or Ryles tube in a bowl of ice
Lubricant such as water soluble jelly or glycerin or liquid paraffin
Purpose: to clean the nostrils.
Adhesive plaster and scissors
Purpose: to fix the tube in position.
Rag pieces in a container
Purpose: to wipe the secretions.
Purpose: to collect the wastes.
Clean syringe or a funnel in a tray
Purpose: to aspirate the gastric contents and to give the feeding.
A glass of feed in a bowl of warm water
Purpose: to give the feed at the body temperature.
Purpose: to measure the fluid intake.
A bowl with water
Purpose: to test the location of the tube.
Purpose: to clamp the tube to prevent leakage of gastric contents.
Purpose: to clear the airway in case of unconscious or seriously ill client who vomits and aspirates the fluid into the respiratory tract.
Preparation of the Client and the Unit
1. Explain the procedure to the client, if the client is conscious, to gain his confidence and cooperation.
2. Explain the sequence of procedure and explain how the client can cooperate with you.
3. Provide privacy.
4. Provide a safe and comfortable position for the client. If the general condition of the client permits, make the client sit on the chair or place him in Fowler’s position. If the general condition is weak, raise the head with extra pillows.
5. Place the mackintosh and face towel across the chest and under the chin to protect the garments and the bed linen.
6. Allow the client to adjust the kidney tray according to his convenience or keep the kidney tray next to the client ready to use if he vomits.
7. Remove the dentures, if any, and place it in a bowl of clean water.
8. Arrange the articles conveniently on the bedside locker.
9. Give a rag piece in the client’s hand to wipe the face and lips when necessary.
10. Give a mouth wash and help them to clean the teeth.
11. Clean the nostrils, if there is secretion or crust formation, using swab stick dipped in saline or soda-bicarb solution.
1. Wash hands.
Reason and Explanation: to prevent cross infection.
2. Take the tube and check whether it is in good order. Expel the water from the tube and check the tube for patency.
Reason and explanation: any blockage should be corrected before introducing the tube. If any water is remaining in the tube, it can dribble into the trachea and choke the client.
3. Measure distance on the tube from the bridge of the nose to the ear lobe plus the distance from the ear lobe to the tip of the xiphoid process of the sternum. Mark the distance of the tube.
Reason and explanation: rough guide to determine approximate length of the tube to reach the stomach.
4. Lubricate the tube for about 6 to 8 inches with the lubricant, using a rag piece or a paper square. Lubricant should be applied to the minimum.
Reason and explanation: lubrication of the tube reduces friction between mucus membrane and the tube. If the lubricant is excessive, it may dribble into the trachea during the intubation and cause respiratory distress.
5. Hold the tube coiled in the right hand and introduce the up into the left nostril.
Reason and explanation: nasal septum is deviated into the right side.
6. Pass the tube gently but quickly backwards and downwards. Momentary resistance may occur as the tube is passed into the nasopharynx. Have a client to flex the head. Withdraw the tube about one inch, rotate it side to side and gently advance the tube.
Reason and explanation: flexing of the head helps to flex the tube at the naso-pharyngeal junction and the tube enters the pharynx. Stop if there is marked resistance and inspect the posterior cavity for coiled tubing.
7. When the tube reaches the pharynx the client may gag. Allow him to rest for a moment. Ask him to take panting breaths.
Reason and explanation: panting reflexes the pharynx. A brief pause may prevent vomiting.
8. Having the client take sips of water and swallow on command. Advance the tube 3 to 4 inches each time client swallows. Continue to advance the tube until it reaches the previously designated mark.
Reason and explanation: swallowing facilitates the swallowing of the tube through the oesophagus. Mark on the tube indicates the tube has reached the stomach.
9. Excessive gasping, coughing and cyanosis are signs of respiratory distress. The tube may be in the trachea. Immediately pull it out.
Check the placement of the tube in the stomach.
Aspirate for gastric contents with a syringe.
Reason and explanation: fluids cannot be freely aspirated from the lungs.
Place the end of the tube with a syringe barrel or funnel into the bowl of water and note the rhythm of escaping bubbles.
Reason and explanation: if the tube is in the trachea, air bubbles will coincide with the expiration of each breath.
Ask the client to hum or speak.
Reason and explanation: the client will be unable to hum or speak if the tube is in the trachea.
10. After the tube is in place, tape it to the side of the face and wait for sometime before giving the feed.
Reason and explanation: careful fixing of the tube prevents it from being displaced. A few minutes rest will help to subside the peristalsis and prevent nausea and vomiting.
11. Before giving the feed, pour some water through the funnel and lower the funnel slowly, so as to expel the air. Then give the feed and the medicines kept ready for the client. When the feed is finished, pour a little water and clamp the tube firmly to prevent leakage of fluids.
Reason and explanation: expelling the air from the tube before the feed is given, not allowing the fluid to run completely, clamping the tube at the end of each feed, are some of the measures to prevent the entry of the air into the stomach.
After Care of the Client and Articles
1. Offer a mouthwash. Clean the face and hands and dry them.
2. Remove the mackintosh and towel.
3. Make the client comfortable in bed.
4. In case of unconscious or seriously ill clients, apply suction if secretions are collected in the mouth.
5. Take all articles to the utility room. Discard the wastes and clean the articles with soap and water. Dry them. Replace them into their proper places.
6. Wash hands.
7. Record the time, date, amount of feed, the nature of the feed, the reaction of the client if any, in the nurse’s record as well as in the intake and output chart.
8. Remove the tube when the tube feeding is to be stopped.
Insertion of the Orogastric Tube
Oral insertion of the gastric tube follows the same guidelines as in nasal insertion except the following points:
1. Premeasure the tube from the lips of the sternum.
2. To facilitate the passage of the tube, ask the client to suck on the tube as if it were a straw and swallow at the same time.
Gastrostomy Feeding/Jejunostomy Feeding
Feeding by gastrostomy and jejunostomy has been used when tumors, fistulas or operations on the upper alimentary tract make it impossible for food to reach the stomach and intestine by the normal route. A part of the stomach or small intestine is brought to the abdominal wall and an opening is made into it through the abdominal wall. A tube is inserted into it through which feedings can be given. It is essential that the area of the skin around the tube be kept clean and dry. A waterproof ointment such as zinc oxide may be applied around the tube to protect the skin from the irritation of the hydrochloric acid. Food is given through the gastrostomy tube as same as those given by nasogastric tube and the same amounts are given at the same intervals.
Tube Feeding (Gastric Gavage) – Nursing Procedure and Responsibility.