Chapter 18: Care of a Client with a Tube

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Ever feel like you're just drowning in medical terms and procedures?

You know, you're trying to grasp something, maybe even basic, and suddenly it's all just noise.

Oh, absolutely.

Information overload is definitely real, especially with complex medical stuff?

Well, that's exactly what we're tackling today.

We're doing a deep dive into one specific chapter, Care of a Client with a Tube, from the Saunders Comprehensive Review for the NCLE -XPN Examination, 7th edition.

Right, think of this as your shortcut, maybe.

We're extracting the need -to -know info about all sorts of medical tubes.

We're digging into this really comprehensive nursing review text so the information is solid.

Our mission.

To kind of demystify these devices.

Yeah, clarify their purpose, the procedures, and, super importantly, the safety measures you need to know, without getting bogged down in every tiny detail.

Exactly.

This is for you, the learner.

We know you want that quick, solid understanding, those ah -ha moments that make it all click.

Like that tricky scenario with the cracked chest tube they mentioned, we'll definitely circle back to that.

Okay, perfect.

Let's start unpacking this.

How about we begin with something pretty common, nasogastric tubes.

NG tubes.

Sounds good.

So an NG tube, basically, it's a tube that goes through the nose, down the esophagus, and into the stomach.

Stomach intubation, essentially.

Got it.

Nose to stomach.

Why would someone actually need one?

What are the main reasons?

Well, the chapter lists six key purposes.

First off, decompression.

That's removing gas or fluid to relieve pressure.

Okay, like if the stomach's really distended.

Exactly.

Second, it lets surgical connections and esomoses heal without being stretched.

Third, it helps lower the risk of aspiration, you know, breathing stomach contents into the lungs.

Especially crucial for patients who can't swallow well or aren't fully alert.

Right.

Fourth, giving medications if they can't take them orally.

Fifth,

temporary feeding.

And sixth, gastric irrigation, washing out the stomach.

Like in cases of poisoning, maybe?

Precisely.

To remove toxins.

No, are all NG tubes the same?

I think the book mentions different kinds.

It does, yeah.

Figure 18 -1 shows a few.

But the one they really highlight is the Salem sump tube.

It's interesting because it has the separate air vent, like a little blue pigtail, usually.

An air vent.

What's that for?

It acts like a pressure release.

It prevents the main suction tube from latching onto the stomach lining and causing damage.

So critically, you never clamp that air vent.

Never clamp it.

Got it.

And you need to keep it above the level of the stomach to prevent stomach contents from siphoning out.

Okay.

Good tip.

What if it starts leaking fluid, though?

That seems like it could happen.

The book gives a clear troubleshooting step.

Gently inject about 30 millimillers of air into the vent, and then you can irrigate the main tube with normal saline if needed.

Some also have an anti -air flux valve to help prevent that leakage.

Clever.

Okay.

Insert in the tube.

Box 18 -1 covers the procedure.

We don't need every single step, right?

But what's the gist?

The gist is always follow your facility's specific protocol, and before you even start, you absolutely have to check that the tube itself is patent, that it's not blocked.

Makes sense.

So the tube's in.

Irrigation seems important for keeping it working.

How's that done?

Okay.

First rule.

Always, always check placement before putting anything down the tube.

Anything.

Crucial.

Check placement first.

Then, irrigation is usually done about every four hours to keep it clear.

Typically, 30 to 50 milliliters of water or normal saline, but check the policy.

Big exception, though.

If the patient had gastric surgery, you need a specific doctor's order before you irrigate anything.

Right.

Don't want to disrupt healing sutures.

And how do you know if it's clear after irrigating?

You gently instill the fluid, then try to pull back.

If you can withdraw fluid easily, it's patent.

If not, might need to reassess or try again gently.

Okay.

So putting it in, keeping it clear.

What about taking it out when it's no longer needed?

Removal has a few key steps.

First, a little saline flush to clear the tube helps prevent aspiration on the way out.

Good idea.

Then, you ask the patient to take a deep breath and hold it.

That closes off the airway temporarily.

Then, it's a slow, steady pull.

Takes about three to six seconds.

Coiling the tube around your hand as it comes out helps manage it.

Seems pretty straightforward.

Okay, let's shift gears slightly to gastrointestinal tube keyings.

This feels related, but distinct.

It is.

This is all about providing nutrition directly into the GI tract when someone can't eat normally.

The chapter talks about different tube types based on where they end up.

Right.

We mentioned NG tubes going to the stomach.

What else?

There are nissodeuodenal or nissodejunal tubes starting in the nose, but going further down into the small intestine, the duodenum or jejunum.

And then, you have tubes placed directly through the abdominal wall, gastrostomy tubes or G tubes into the stomach,

and jejunostomy tubes, J tubes, into the jejunum.

Different routes for different situations.

And how the feeding itself is given varies, too, right?

Bolus, continuous, cyclical.

Exactly.

Let's break those down.

Bolus feeding is kind of like a meal, a set amount given over 30 to 60 minutes, maybe every three to six hours.

Mimics normal eating patterns.

Sort of.

Continuous feeding runs 24 -7, usually controlled very precisely by a pump.

All day, all night.

And the cyclical feeding is somewhere in between.

It runs for a set period, like 8 to 16 hours, often overnight, also on a pump.

Ah.

The overnight option sounds good for letting people be more mobile during the day.

It definitely can be.

Now, actually, administering these feedings, there are a lot of important checks.

I bet.

What's first?

Always check the doctor's order, of course.

And check the facility policy on checking residual volume.

That's the stomach contents left over from the last feeding.

Residuals.

Okay, why check that?

Because a large amount, usually over 100 mL, is a common cutoff.

But check policy might mean the stomach isn't emptying well.

That increases the risk of aspiration.

Oh, makes sense.

What else before you start?

Listen for bowel sounds.

You really shouldn't feed if bowel sounds are absent.

Notify the RN.

No sounds, no food.

Got it.

Positioning is key, too.

High Fowler's position is best.

If the patient is unconscious, high Fowler's tilted slightly to the right side can help emptying.

And, again, confirm tube placement.

Aspirate some contents.

Check the pH stomach contents should be acidic, pH 3 .5 or less, usually.

Or follow whatever your facility's method is.

Placement, placement, placement.

It seems like a recurring thing.

It's a theme for safety.

Once placement's confirmed, you aspirate all the residual, measure it.

And unless it looks weird, like old blood, or there's a huge amount, maybe over 250 milliliter, depending on policy, you put it back in.

Put it back in what?

To prevent electrolyte imbalances.

That fluid has electrolytes the body needs.

Oh, okay.

Then the feeding itself.

Warm it to room temperature cold formula can cause cramps and diarrhea.

Use a pump for continuous or cyclical feeds.

For bolus feeds, keep the patient sitting up for at least 30 minutes after.

Use gravity or a pump, but never plunge the feeding in fast with the syringe.

No plunging.

Got it.

And for continuous feeds.

They need to stay in at least a semi -fowler's position the whole time the feeding is running.

Seems like a lot can go wrong.

The book highlights some major precautions, right?

There's one bold.

Yes.

And it's worth repeating.

Always check the placement before instilling anything.

Feedings, meds, water flushes, anything.

It's all about preventing aspiration.

Okay.

Change the feeding bag and tubing every 24 hours.

Bacteria.

Love that stuff.

Don't hang more than a four hour supply of formula unless it's a special closed system.

Check expiration dates.

Shake the formula well.

Standard stuff, but important.

Yep.

And remember,

check bowel sounds before feeding.

Administer at the prescribed rate.

Flush the two well 30 to 50 millimiters of water or saline after bolus feeds.

And every four hours during continuous feeds.

Flushing prevents clogs, I assume.

Clogging sounds like a nightmare.

It can be.

The chapter discusses preventing complications for diarrhea.

Watch for lactose intolerance.

Consider fiber formulas.

Administer slowly and at room temp.

Increase the rate gradually.

Okay.

And aspiration.

We covered the prevention.

Check placement.

Check residuals.

Keep the head elevated.

If it does happen, suction immediately, monitor breathing, lungs, temperature closely for pneumonia and anticipate a chest x -ray.

And the dreaded clogged tube.

Prevention is key.

Use liquid meds if possible.

Crush pills really well if you have to use them.

Flush, flush, flush, before and after meds, before and after bolus feeds, every four hours for continuous.

And if it still clogs?

Try gentle irrigation first.

If that doesn't work, you'll need to notify the provider.

Vomiting is another one.

How do you handle that?

Prevent it by giving feeds slowly.

Bolus feeds should take at least 30 minutes.

Keep an eye on abdominal girth for distension.

Don't let the bag run dry.

Avoid air in the tubing.

Use room temp formula.

Keep the head up.

Antimetics might be ordered.

And if they do vomit?

Critical action.

Stop the feeding immediately.

Turn the patient onto their side.

Suction if needed.

Protect that airway.

Got it.

Stop, turn, suction.

Okay, what about giving medications through these tubes?

There's a priority nursing actions box for that.

Yes, signals importance.

It's a 10 -step process, basically.

Check the order.

Prepare the med liquid form as best.

If not.

Ensure it can be crushed or opened.

Dissolve it thoroughly in 1530 mL water.

Okay.

Verify the patient, explain.

Check tube placement, residual bowel sounds again.

Always checking.

Draw med into a catheter -tipped syringe, no air.

Instill it gently.

Flush with 3050 mL water saline.

Then what?

Clamp it?

Yes.

Clamp the tube for about 30 to 60 minutes, depending on the med and policy.

This gives it time to absorb before suction might pull it back out.

Ah, okay.

That makes sense why you'd clamp it then.

And finally, document everything.

The box also reminds you to consider contraindications, interactions, and any extra assessments needed, like checking pulse or blood pressure for certain meds.

Very thorough.

All right, moving on to intestinal tubes.

These sound like they go deeper.

They do, nose into the small intestine,

usually used for bowel decompression when other things haven't worked.

They have a weighted tip, often tungsten, to help them pass through the pylorus, the valve leaving the stomach.

Weighted tip.

Interesting types.

Cantor and Miller Abbott are mentioned, shown in figure 18 to 1.

Key interventions involve following orders for advancing the tube, often assisting the RN.

Position the patient on the right side to help it pass through the pylorus.

Right side positioning, okay.

Don't take it down right away.

Wait until it reaches its final spot, which can take hours.

Monitor the abdomen, drainage, girth.

If it gets blocked, notify the RN provider.

Removal is gradual, maybe six inches an hour per order after removing the tungsten with the syringe.

Okay.

Next up, esophageal and gastric tubes.

These sound serious.

They are.

Think Singstaken -Blakemore or Minnesota tubes.

They're used to apply pressure directly to bleeding esophageal varices, those swollen veins in the esophagus.

Usually from liver disease.

Often, yes.

It's a last resort when other methods fail or aren't possible.

Big contraindications.

Esophageal ulcers, tissue death or previous surgery, high risk of rupture.

Sclerotherapy during endoscopy is often preferred now, but these tubes are still sometimes needed.

Sounds risky.

What's the key nursing care?

Critical care.

Check balloon integrity before insertion.

Label all the lumens clearly.

Patients it's upright.

Expect an immediate post -insertion x -ray for placement.

Keep the head elevated.

Double clamp balloon ports to prevent leaks.

And here's a huge one.

Keep scissors at the bedside at all times.

Scissors?

Why?

If the gastric balloon ruptures, the tube can slide up and block the airway.

You'd need to immediately cut the tube ports to deflate all balloons fast.

It's an airway emergency.

Wow.

Okay.

Scissors readily available.

What else to watch for?

Respiratory distress, notify the RN immediately.

Cut tubes if needed.

Increased bloody drainage suggests ongoing bleeding.

Signs of esophageal rupture drop in BP.

Fast heart rate.

Back or upper abdominal pain.

That's another emergency.

Report stat.

High stakes.

Okay.

Quick mention of lavage tubes.

Right, used for gastric lavage washing out the stomach, like after ingesting toxins.

Lavacuator and e -walled tubes are examples.

Large bore tubes for quick removal.

Got it.

Now, shifting to urinary and renal tubes.

Different types of catheters.

Yep.

Single lumen, that's your straight cath for emptying the bladder quickly, getting a sterile sample or checking post -void residual, sometimes using a bladder scanner now.

Okay.

Double lumen, the standard indwelling, fully catheter.

One channel for urine drainage, one to inflate the retention balloon.

Triple lumen used for continuous bladder irrigation, maybe after prostate surgery.

Has channels for inflow, outflow, and the balloon.

Big emphasis in the chapter.

Strict aseptic technique for insertion and care is non -negotiable.

Aseptic technique.

Understood.

And routine care.

Gloves.

Warm, soapy water for perineal care.

Clean along the catheter.

Anchor it securely to the thigh, per policy.

Keep the drainage bag below the bladder level, always.

Prevent dependent loops in the tubing.

All to prevent CIUTs.

Catheter -associated infections.

Exactly.

Get the catheter out as soon as it's not needed.

Use securement devices.

What about ureteral and nephrostomy tubes?

They go higher up.

Yes, into the ureters or directly into the kidney.

Critical point here, never clamp these tubes.

Never clamp, okay.

Maintain patency.

Monitor output very closely.

Less than 30 mL per hour or no output for 15 minutes.

Report that immediately.

Irrigation might be ordered, but usually done by the RN per specific protocol.

Got it.

Insertion and removal of regular urinary catheter's box.

18 to 2 again.

Highlights.

Proper positioning.

Sterile technique throughout.

Lubication.

Inserting the correct distance they give measurements for female and male patients.

Wait for urine return before advancing a bit more.

Inflate the balloon fully.

Secure it.

Document everything meticulously.

And removal.

Similar position.

Remove tape.

Deflate the balloon completely.

Tell the patient they might feel a burning sensation.

Smooth, slow removal.

Then monitor their voiding pattern for the next 24 hours.

Time and amount of first void is important.

Okay, makes sense.

Now, respiratory system airway tubes?

Endotracheal or ET tubes first?

Right.

Used to maintain a patent airway, often for mechanical ventilation.

If needed longer than, say, 10 -14 days, a tracheostomy is usually considered to avoid damaging the vocal cords or tracheal lining.

Two ways they go in, orotracheal and nasotracheal.

Yes.

Orotracheal through the mouth.

Allows a larger tube, so less work of breathing.

Good if there's nasal issues.

Downside.

Can be uncomfortable.

Patient might bite.

They might need an oral airway alongside it.

Okay, nasotracheal.

Through the nose.

Smaller tube, so potentially more resistance, more work of breathing.

Avoid if bleeding issues, but generally more comfortable since they can't move it with their tongue.

How do you know for sure it's in the right place after insertion?

Placement confirmation is vital.

Gold standard is a chest x -ray tip should be 1 -2 centimeter above the carina where the trachea splits.

Uh -huh.

Also, listen for equal breath sounds on both sides while bagging the patient.

If you only hear sounds on the right, it might be down the right main stem bronchus.

Common mistake.

And listen over the stomach too.

Rule out esophageal intubation.

Louder sounds over the stomach, maybe abdominal distension, means it's in the wrong pipe.

Okay, once confirmed.

Secure it immediately tape or a securing device.

Monitor its position at the lip or nose mark.

Check skin, mucous membranes, suction only when needed.

And move the oral tubes.

Yes, switch the oral tube to the opposite side of the mouth daily, needs two people.

Prevents pressure sores, nerve damage allows inspection.

Prevent accidental dislodgement during suctioning or coughing.

Check the pilot balloon to ensure the cuff is inflated properly for a good seal.

Keep the head of the bed elevated over 30 degrees to help prevent ventilator -associated pneumonia, VAP, regular oral care, suctioning the oropharynx.

Some tubes have special ports for suctioning above the cuff.

And always have wet at the bedside.

An AMBO bag.

Always.

Ready to go.

Critical backup.

What about taking the ET tube out extubation?

Hyper oxygen at first.

Suction the ET tube and mouth well.

Semi -fowler's position.

Deflate the cuff completely.

Instruct patient to inhale and remove the tube quickly at peak inspiration.

Maybe suctioning on the way out.

Encourage cough, deep breathing.

Apply oxygen as ordered.

Monitor closely for any respiratory difficulty.

Let them know hoarseness or sore throat is normal initially.

Advise limiting talking.

Got it.

Now tracheostomies, surgical airway.

Exactly.

And opening directly into the trachea.

A track tube is inserted, can connect to a vent or O2, can be temporary or permanent.

Key care points for tracks.

Monitor breathing, bilateral breath sounds, O2, SATs, ABGs.

Encourage coughing, deep breathing.

Keep head elevated semi to high foulers.

Watch for bleeding, difficulty breathing.

Crepitus could signal pneumothorax or hemorrhage.

Okay.

Suction as needed.

Hyper oxygenating before.

If they can eat, sit them fully upright.

Ensure cuff is inflated during and for about an hour after meals if the tube isn't capped to prevent aspiration.

Check the stoma site and secretions regularly.

Follow policy for cleaning the site.

An inner cannula often uses half strength hydrogen peroxide.

Though many inner cannulas are disposable now.

Humidified oxygen is crucial because their natural humidification system is bypassed.

Changing ties needs help.

Yes, always get assistance.

Secure the new ties before cutting the old ones.

Some use Velcro ties now.

And the emergency kit at the bedside.

Absolutely essential.

Ambu bag, obturator, clamps, and a spare track tube set of the same size.

Maybe one size smaller too.

Frequent mouth care is also key to prevent pneumonia.

Table 18 -1 lists complications.

It does.

We won't list them all, but be aware they exist.

One critical safety note.

Never insert a decannulation plug which blocks the tube unless the cuff is deflated.

A and D, the inner cannula is removed.

Otherwise, the patient can't breathe at all.

Huge safety point.

Very finely, chest tube drainage systems look complex.

They have a few parts, but the goal is simple.

Restore negative pressure in the pleural space, the space around the lungs, and drain abnormal air or fluid.

Figure 18 -5 shows typical placement sites.

What are the main parts of the system?

Figure 18 -6 shows one type.

Usually three chambers.

First, the drainage collection chamber.

Connects to the patient's tube, collects the fluid, it's calibrated so you can measure output.

Okay, collects the drainage.

Second?

The water seal chamber.

The tube end sits underwater, acts as a one -way valve, air and fluid can get out, but air can't get back into the chest.

Makes sense.

What do you look for here?

You should see the water level rise and fall slightly with breathing that's called titling or fluctuation.

If there's pneumothorax, you might see intermittent bubbling as air escapes.

But excessive continuous bubbling here usually means an air leak in the system.

Continuous bubbling, air leak.

Got it.

Third chamber.

The suction control chamber.

This regulates the amount of negative pressure applied.

In water seal systems, it's filled with water to a specific level, say, negative 20 centimeters.

Gentle, continuous bubbling in this chamber is normal and expected when suction is on.

It just shows the suction is working.

So gentle bubbling in suction control is okay, but continuous bubbling in water seal is bad.

Exactly.

Don't confuse the two.

Vigorous bubbling in the suction control chamber might mean the wall suction is too high or could indicate a leak too.

The book also mentions dry suction systems.

Right.

No water in the suction control part.

You dial the suction level on the device itself.

Wall suction is turned up until an indicator, maybe an orange float appears in a window.

No bubbling to monitor in the suction control part of these.

And portable ones.

Yep.

Smaller, use a flutter valve.

Same principles.

Allow more ambulation.

Even home use sometimes.

Okay, so what are the absolute must -do nursing actions for chest tubes?

Monitor drainage in the collection chamber.

Notify the provider if it's over 70, 100 mAh, or suddenly bright red, or increases dramatically.

Mark the level regularly.

Check.

Watch the water seal chamber for titling.

If titling stops, check for kinks, obstructions, dependent loops, or maybe the lung has re -expanded.

Check for that continuous bubbling indicating an air leak.

Ensure gentle bubbling in the water -filled suction control chamber if suction is on.

Maintain a sterile occlusive dressing at the insertion site.

Expect chest x -rays to check position and lung re -expansion.

Assess the patient.

Constantly.

Respiratory status, lung sounds.

Watch for signs of worsening pneumothorax or hemothorax distress, crepitus, increased drainage.

Keep the system.

Below chest level.

Keep tubing free of kinks and dependent loops.

Ensure all connections are tight.

Yeah.

Coffee and deep breathing.

Frequent position changes.

Ambulation might be possible if stable, even with suction off briefly.

Just leave tube open to air.

Stripping or milking the tubes?

Generally not done unless specifically ordered and policy allows.

It can create dangerously high negative pressure.

What should be at the bedside?

A clamp for changing the system if needed and sterile occlusive dressing materials like petroleum gauze.

Clamping the tube itself.

Never without a specific order and checking policy can cause tension pneumothorax.

What if the system cracks or breaks?

Emergency.

Notify RN immediately.

Disconnect tube from system and submerge the end immediately in sterile water creates a temporary water seal.

Then replace the system.

Got it.

Submerge in sterile water.

Removal.

Patient takes deep breath and holds it or performs Valsalva maneuver per order.

Tube out quickly.

Apply dressing dry, sterile, or petroleum gauze type.

And the ultimate emergency tube gets pulled out completely.

Act fast.

Pinch the skin open and closed immediately.

Cover with a sterile occlusive dressing, taped securely on three sides usually or fully depending on policy.

Call RN and provider stat.

OK, that was a lot.

So let's circle back to that critical uniking question.

The cracked chest tube system.

What's the immediate action?

Right.

The immediate action is notify the RN.

Then to protect the patient while waiting for help or getting supplies,

disconnect the chest tube from the broken system and stick the end of the tube into a bottle of sterile water.

Creates that temporary water seal.

Exactly.

Prevents air rushing back into the chest.

Then the RN will replace the whole system following policy.

It really underscores why you need sterile water and clamps readily available.

But again, don't clamp the tube itself unless ordered and keep everything below test level.

Perfect.

The chapter wraps up with practice questions which sound incredibly helpful.

They really are.

They test your understanding of everything we've discussed.

NG residuals, ET suctioning issues, chest tube findings, sank -stake and Blakemore emergencies,

catheter insertion, tube feeding management, meds via tube, crepitus, track types.

The works.

And they provide answers with rationales.

Which is key for learning why an answer is right or wrong.

Great for self -assessment.

Well, we have certainly covered a lot of ground in this deep dive on the care of a client with a tube.

From NG tubes, feedings, intestinal tubes.

To esophageal, gastric, lavage tubes, urinary and renal catheters, ET tubes, tracts and chest tubes.

Quite the tour.

Our goal was really to pull out the core concepts.

The purpose, the main procedures, and those are critical safety points for each device.

And hopefully this gives you, the listener, a solid foundation, that short -tut to understanding we talked about, making it feel a bit less overwhelming.

We really encourage you to think about which of these devices and procedures pop up most in your learning or your practice.

Maybe go back and look at those figures and tables in the chapter for visual reinforcement.

Yeah, and if questions linger, definitely seek out answers.

Talk to instructors, colleagues,

dig a bit deeper.

And maybe a final thought to leave you with.

Medical technology is always changing, always evolving.

Absolutely.

So, what's our role as nurses in keeping up with these new devices and procedures, ensuring we adapt while always, always prioritizing patient safety?

Something to keep thinking about.

Indeed.

And with that, we've reached the end of our comprehensive look at this chapter.

We've hit all the key sections aiming for clarity and covering those essential nursing interventions and safety protocols.