Nasogastric Tube Insertion

Subject: Fundamentals of Nursing

Overview

Nasogastric Tube Insertion

Nasogastric tube insertion is a method of introducing a tube through nose into stomach. Sometimes this tube iss inserted through the patient's mouth into the stomach that is called an 'orogastric' tube.

NG Tube

It is made up of polyvinyl chloride.

Size of NG Tube: Size of NG tube should select as per the  age of the person.

Age NG-tube (Fr)
0-6 months 8-10
1 year 10
2 years 10
3 years 10-12
5 years 12
6 years 12
8 years 14
12 years 14-16
Adults 14-18

Purposes

  • to relax and empty the stomach.
  • to dilute and eliminate toxin ingested (gastric lavage).
  • to measure the GI tract's motor activity and pressure levels.
  • to feed a patient who is unable to swallow food (gastric gavage).
  • by decompressing the stomach, to prevent or reduce nausea and vomiting during surgery or stressful situations.
  • When a patient is unable to take oral medicine, water, or nourishment, to offer a channel for delivery.
  • to offer a method for carrying out diagnostic procedures and obtaining samples for laboratory research.

General Instructions of Tube Insertion

Tube: The tip of the tube is lubricated with sterile paraffin or jelly. (Distal 10-15 cm of the tip is lubricated with water soluble lubricant)

Nose: Wider nostril is selected. Nostril is cleaned with swab stick, moistened with normal saline (Ns)

Position: The position of the patient should be sitting; high fowler's position or when the patient is lying, the head should be flexed by one hand.

Contraindications of NG Tube Insertion

  • Acute corrosive poisoning,
  • Nasal lesions or polyps,
  • Deviated Nasal Septum (DNS),
  • Disease in oesophagus,
  • Oesophageal varices,
  • Patients with respiratory distress,
  • Cardiac disease patients.

General Principles

  • Easy insertion is made possible by a detailed understanding of the respiratory and digestive systems' architecture and function.
  • Ensure the tube is inserted safely.
  • Microbes get into the body through food and beverages.
  • The client will fight any effort to insert the tube into their mouth or nose since it is a terrifying condition.
  • The client's physical and mental preparation makes it easier to insert the tube.
  • The comfort and safety of the customer are increased by systematic working methods, which also aid in material economy.
  • Auscultation is not a good approach for confirming the insertion of nasogastric tubes since a tube accidentally inserted in the throat, esophagus, or lungs also emits a sound that is similar to air entering the stomach.

Articles Required

  • Trolley/tray containing:
    • Kidney tray,
    • Towel/Makintosh,
    • Flash light,
    • Nasogastric feeding tube with radio-opaque line (8 to 12fr),
    • Water soluble lubricant/xylocaine jelley N Blue litmus paper/ PH indicator strip,
    • Clamp,
    • Suction apparatus,
    • Tongue depressor if needed,
    • Clean gloves,
    • Syringe (The size should not be less than 10 ml).
    • Stethoscope,
    • Gallipot with water,
    • Drinking water and straw for the patient to drink (unless contra-indicated).
    • Fixative tape/Scissor,
    • Gauze pieces,
    • Measuring cup or marked drinking cup.

Procedures

S.N. Nursing Action Rationale
1 Identify the patient. Helps in determining the appropriate size of the nasogastric tube for patient.
2 Assess patient for the need for NG tube insertion: NPO, insufficient intake for more than 5 days or unable to ingest sufficient nutrients. Determines the purpose of NG tube insertion.
3 Check the physician's order for any precautions such as for positioning or movement. Ascertains the procedure.
4 Explain the procedure to the patient. Assure his/her that the procedure is not painful and the discomfort caused while inserting the tube is only temporary. Reduces anxiety and promotes client's participation.
5 Maintain privacy. Close the door/curtain and switch off the fan. Ensures privacy. Prevents spread of dust and microorganisms.
6 Wash the hands thoroughly. Prevents chance of cross infection.
7 Arrange the articles in bed side. Ensures an organized approach towards carrying out procedure.
8 Raise the bed at comfortable height. Facilitates insertions of the tubes and reduces risk of aspiration.
9 Place the patient in a high fowler's position, comatose patient in semi fowler's position. Elevate the head of the bed 45 degrees.  
10 Place the mackintosh and towel across the chest. Prevents soiling of client's cloths.
11

Measure the length of the tube, from tip of nose to tip of the ear lobe and to the tip of xiphoid process and mark with tape. For oro-gastric intubation, the stomach. tube is measured from the lips to the tip of xiphoid process of sternum.

Mark measured length with a marker or note the distance.

 The measured length approximates the distance from the nose to the stomach.
12 Cut the adhesive tape about 10 cm long. Helps to adjust the tube in the right place.
13 Put on the clean gloves. Prevents cross infection.
14 Clean the nostril through the wet swab sticks with normal saline. Ensures clean area.
15

Check the patients' for deviated septum, nasal polyps, deformity or obstructions.

Assess for gag reflex placing tongue blade in patient's mouth.

Auscultate the bowel sounds.

Helps to determine best side for insertion and to identify ability to swallow and determine if there is risk for aspiration. 

Absence of bowel sound indicates decreased or absence of peristalsis and risk for aspiration and or abdominal distention.
16 Lubricate the tip of the tube about 6-8 inches with water soluble lubricant using a gauze piece.  Lubrication reduces friction between mucous membrane and tube.
17 Hold the tube coiled in your right hand with the tip in between thumb and index finger. Ensures easy insertion.
18

Insert the tube gently and instruct the patient to swallow until the tube reaches the stomach.

Advance tube 3-4 inches each time patient swallows until desired length has been passed.

Advance tube until mark is reached.

If the patient coughs, pull the tube a little bit and re-insert it.

Flex the patient's head towards the chest after the tube has passed the nasopharynx.

Examine the patient's mouth and back of throat using a tongue blade and pen lights.

Natural contours facilitate the passage of the tube.

The tube may be coiled, kinked or entering trachea.

 
19 If there are signs of distress such as gasping, coughing or cyanosis, pull back the tube for some length and check if patient's distress is reduced. If it is relieved re-insert after few seconds. If the patient develops respiratory distress again, immediately remove the tube. The tube may have entered the trachea.
20

Make sure that the tube is in the stomach and not in the lungs; check it by the following methods:

Aspirate the gastric content and check the PH using the blue litmus paper if available. Place the drop of gastric secretions onto PH paper. Within  30 seconds, compare the color on the paper with the chart supplied by the manufacturer. 

Visualize aspirated contents, checking for color and consistency.

Place the end of the tube in bowl of water to  check for continuous air bubbles in water

Ask the patient to speak.

Place the stethoscope over the epigastric region and attach the syringe to the free end of NG tube and push 10-20 ml of air through the tube, listen  for air sound/bubble sound/wheezing sound of the air entering to the stomach.

X-ray may be done to identify the placement of tube.

Aspirated contents indicate that the tube is in the stomach.

Continuous bubbles indicate that tube is in the respiratory tract. 

The patient will not be able to speak if the tube is in the trachea.

If wheezing sound from the input at the air is heard, this suggests the tube is in the stomach. 
21 Secure tube with tape. Use a 10cm/4 inches piece of tape, split at one end. Place intact end of the tape over bridge of nose. Carefully wrap 2 ends around tube. Connect the outer open end of the tube funnel. Tape helps to secure tube.
22 Clamp the tube and cap or attach the tube to suction according to the orders. Ensures proper functioning.
23 Secure the tube to the patient's gown by using rubber hand or tape. Make the patient comfortable in bed. Reduces friction on nares when patient moves.
24 Provide oral hygiene every 4-6 hours. Prevents from infection.
25 Remove all equipment, lower the bed, remove gloves and perform hand hygiene. Promotes client's comfort and  reduces transmission of microorganisms.
26 Record in the patient chart: date, time, purpose of nasogastric tube insertion, size of the tube inserted patient's reaction to the procedure. Documents exact procedure.

Points to be remembered:

  • Select correct size.
  • Keep in correct position.
  • Ensure correct placement of tube.
  • Remove the tube immediately if respiratory distress arises.

Removal of Nasogastric Tube

It is a method of withdrawing or drawing out the nasogastric tube from the nose.

Purpose

To remove the tube when it is not necessary

Articles

A tray containing:

  • Mackintosh
  • Towel
  • Plastic bag or kidney tray
  • Clean gloves
  • Clamps
  • Gauze pieces or tissue paper
  • Syringe 30 ml, 50 ml (optional)
  • Normal saline solution for irrigation (optional)

Procedure

S.N. Nursing Action Rationale
1 Check the physician's order for removal of NG tube. Proper assessment will provide information and instructions.
2 Explain procedure to the patient. Close door and pull the screen. Reduces anxiety and promotes client's participation. Provides privacy.
3 Wash hand and apply disposable gloves. Prevents from infection.
4 Collect required equipment.  
5 Keep the client in sitting position if patient is conscious.

Upright position ensures easy removal.
6 Place mackintosh and towel across the client's chest, give tissues or gauze piece to client. Protects client and bed linen from soiling.
7 Disconnect nasogastric tube from the drainage bag. Helps to remove tube from nose.
8 Remove the tape from the bridge of the nose and from the gown.  
9 Stand on the patient's right side if right handed, left side if left handed. Ensures easy to perform procedure.
10 Instruct the client to take a deep breath and hold it. Promotes comfort.
11 Grasp the tube with right hand. Pinch the tube with fingers or clamp. Ensures easy insertion.
12 Quickly and smoothly withdraw the tube. Quick and smooth withdrawing tube minimizes the discomfort.
13 Place the tube in a plastic bag or kidney tray. Proper disposal of tube helps to prevent infection.
14 Measure nasogastric drainage. Ensures total output.
15 Clean the nose and inspect the condition of the nose; offer water to rinse the mouth if the patient is conscious. Promotes comfort.
16 Position the patient comfortably.  
17 Clean the equipment and return to proper place. Prevents from growth of organisms.
18 Remove gloves and wash hands. Prevents from infections.
19 Palpate the patient's abdomen periodically; noting distention, pain and auscultation for the presence of bowl sound. Assures the patients conditions.
20 Do recording and reporting of removal of nasogastric tube, date, time of procedure, colour and amount of drainage and abnormalities. Ensures right communication of the procedure.
Things to remember

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