NASOGASTRIC TUBE INSERTION

(A SELF-INSTRUCTIONAL PACKAGE)

Arianne L. Garcia, RN
Angeles University Foundation
Masters in Nursing
Nasogastric Tube Insertion its How’s and Why’s
Approximately 2-3 hours working time
 Introduction

This instructional package was made to provide an in depth knowledge

about Nasogastric Tube (NGT). It will guide you through the process of
insertion of the NGT; its indications and contraindications, the equipments to
be used, its complications and special considerations. This will be helpful as
part of your nursing procedures done on a hospital setting.

Objectives

After the completion of this package, you will be able to:

 Have an overview of NGT and all the significant information for its
insertion.
 Describe and understand what a NGT is through the help of some
comprehensive practice questions found after every input.
 Identify the different purpose or indications why the NGT was inserted.
 Identify and be aware of the different contraindications before the
insertion of the NGT.
 Enumerate all the equipments needed for the insertion of the NGT.
 Learn and understand the step by step procedures of its insertion and
the rationale for its procedures.
 Identify different methods on how to check tube placement.
 Identify and state the different complications that may arise upon the
insertion of a NGT.
 Understand nasogastric procedure by answering correctly all the post
test questions found before the end of this package.

Overview
 An alternative feeding method to ensure adequate nutrition includes
enteral (through the gastrointestinal system) methods. Enteral Nutrition
(EN), also referred to as total enteral nutrition (TEN), is provided when the
client is unable to ingest foods or the upper gastrointestinal tract is impaired
and the transport of food to the small intestine is interrupted. Enteral
feedings are administered through nasogastric and small-bore feeding tubes
or through gastrostomy or jejunostomy tubes.

The intestinal tract can influence the outcome of critically ill patients. It
is the largest lymphoid organ in the body. Enteral feeding increases blood flow
to the gut and maintains mucosal integrity, preserves the enterocyte gut-
blood defence barrier, reduces translocation of bacteria and enhances its role
as an immune organ. Immune enhancing diets containing glutamine appear
to reduce the increase in mucosal permeability and also have anti-
inflammatory effects. Enteral nutrition also prevents atrophy of the intestinal
villi and improves substrate utilization. These factors make enteral feeding an
essential component in recovery from illness, and has precedence over
parenteral nutrition.

PRACTICE CYCLE 1

Input

Nasogastric tube is a tube that is passed through the nose and down
through the nasopharynx and esophagus into the stomach, abbreviated as
NGT. It is a flexible tube made of rubber or plastic, and it has bidirectional
potential. It can be used to remove the contents of the stomach, including air,
to decompress the stomach, or to remove small solid objects and fluid, such
as poison, from the stomach. An NGT can also be used to put substances into
the stomach, and so it may be used to place nutrients directly into the
stomach when a patient cannot take food or drink by mouth.
 The word "nasogastric" is a hybrid of the Latin "naso-" from "nasus" for
nose or snout and the Greek "gastric" from "gaster" meaning the paunch or
belly. The term "nasogastric" was coined in 1942.
Before an NGT is inserted, the Health Care Provider - most often the
nurse, must measure with the tube from the tip of the patient's nose, to their
ear and down to the xyphoid process. Then the tube is marked at this level to
ensure that the tube has been inserted far enough into the patient's stomach.
The end of a plastic tube is lubricated and inserted into one of the patient's
anterior nares. It is then moved through the nasal cavity and down into the
throat. Once the tube is past the pharynx, it is rapidly inserted down into the
stomach.
During the tube's insertion, the patient may gag; in this situation the
patient is given water to drink, and the tube continues to be inserted as the
patient swallows. Great care must be taken to ensure that it has not passed
through the windpipe and down into the lungs. To ensure proper placement it
is recommended (though not unequivocally confirmed) that injection of air
into the tube be performed, if the air is heard in the stomach with a
stethoscope, then the tube is in the correct position. Another method is to
aspirate fluid from the tube with a syringe. This fluid is then tested with pH
paper (note not litmus paper) to determine the acidity of the fluid. If the pH is
5.5 or below then the tube is in the correct position. If this is not possible
then correct verification of tube position is obtained with an X-ray of the
chest/abdomen. This is the most reliable means of ensuring proper placement
of a NGT.[2] If the tube is to remain in place then a tube position check is
recommended before each feed and at least once per day.
A commonly used NGT is the Levin tube.

Practice Questions
 Kindly answer the following questions before proceeding to
Practice Cycle 2

1. What do you call of a tube that is passed through the nose and down
through the nasopharynx and esophagus into the stomach?
_________________.
2. What is the special consideration a Health Care Provider should
consider before inserting the nasogastric tube? -
__________________________________.
3. This is the most reliable means of ensuring proper placement of a NGT.
_________________________.

Feedback

Did you say something like?

1. The tube that is passed through the nose and down through the
nasopharynx and esophagus into the stomach is called as
nasogastric tube or NGT.
2. The special consideration a Health Care Provider should consider
before inserting the nasogastric tube is to measure with the tube
from the tip of the patient's nose, to their ear and down to the
xyphoid process.
3. The most reliable means of ensuring proper placement of a NGT is by
obtaining an X-ray of the chest/abdomen.

PRACTICE CYCLE 2
Input

Indication and Purpose

By inserting a nasogastric tube, you
are gaining access to the stomach and its
contents. This enables you to drain gastric
contents, decompress the stomach, obtain
a specimen of the gastric contents, or
introduce a passage into the GI tract. This
will allow you to treat gastric immobility,
and bowel obstruction. It will also allow for
drainage and/or lavage in drug overdosage or poisoning. In trauma settings,
NGTs can be used to aid in the prevention of vomiting and aspiration, as well
as for assessment of GI bleeding. NGTs can also be used for enteral feeding
initially.
A person may need a stomach tube inserted to:
 empty the stomach after a drug overdose or accidental poisoning
 drain the stomach after major trauma, so the person can't inhale
stomach contents into the lungs
 treat malnutrition by giving feedings through the tube. Tube feeding is
also used when a person is unable to eat normally, such as after a
stroke
 keep the stomach relaxed after major surgery to the abdomen, such as
an abdominal exploration
 prevent distension of the stomach when the person has a bowel
obstruction

Contraindications
Nasogastric tubes are contraindicated or used with extreme caution in
people with particular predispositions to injury from tube placement. These
may include:
  Patients with sustained head trauma, maxillofacial injury, or anterior
fossa skull fracture. Inserting a NGT blindly through the nose has
potential of passing through the criboform plate, thus causing
intracranial penetration of the brain.
 Patients with a history of esophageal stricture, esophageal varices,
alkali ingestion at risk for esophageal penetration.
 Comatose patients have the potential of vomiting during a NG insertion
procedure, thus require protection of the airway prior to placing a NGT.
Caution should be utilized when passing a NGT in a patient with suspected
cervical spine injury.
 Excessive manipulation or movement by the patient during placement
including coughing or gagging may potentiate cervical injury.
 Manual stabilization of the head is required during the procedure.

Practice Questions
Kindly answer the following questions before proceeding to
Practice Cycle 3

1. Identify some ways why a NGT is being inserted.

_______________________________________________________________________
_______________________________________________________________________
___________________________________________________.
2. Identify some ways why NGT insertion is contraindicated.
_______________________________________________________________________
_______________________________________________________________________
_________________________________________.
Feedback
 1. Your answers are probably related to one of the indications and
purposes listed previously on the NGT insertion.
2. Your answers are probably related to one of the contraindications listed
previously on the NGT insertion.

PRACTICE CYCLE 3

Input

All necessary equipment should be prepared, assembled and available at

the bedside prior to starting the NGT. Basic equipment includes:

• Nasogastric tube
o Adult - 16-18F
o Pediatric - In pediatric
patients, the correct tube size
varies with the patient’s age. To
find the correct size, add 16 to the
patient’s age in years and then divide by 2 (eg, [8 y + 16]/2 =
12F)
• Viscous lidocaine 2%
• Oral analgesic spray (Benzocaine spray or other)
• Oral syringe, 12 mL
• Glass of water with a straw
• Water-based lubricant
• Toomey syringe, 60 mL
• Tape
 • Emesis basin or plastic bag
• Wall suction, set to low intermittent suction
• Suction tubing and container

Steps or Procedure for NGT insertion with its rationale

Procedure Rationale
1. If possible, explain the procedure 1. The passage if a gastric
to the patient. tube is not painful, but it is
unpleasant because the gag
reflex is activated during
insertion. Establish a
method for the client to
indicate distress and a
desire for you to pause the
insertion. Raising a finger
or hand is often used for
this
2. Wash hands and observe other 2. To prevent cross-
appropriate infection control contamination from secretions
procedures (e.g., clean gloves) between you and the patient, and
vice versa.
3. Position the patient as follows: 3. reduces the curvature of the
nasopharyngeal junction
a. If the patient is awake
and alert-in a sitting
position in high-Fowler’s.

b. If the patient is
obtunded or
unconscious-head down,
preferably in a left side
lying position.
4. Place a protective pad/towel on the 4. To minimize contact with
patient’s chest as well as provide the aspirated gastric contents.
patient with a basin.
5. Using the NGT as a measuring 5. This length approximates the
device determine the length of the distance from the nares to the
NGT to be passed by measuring the stomach. This distance varies
length from among individuals.

a. nose to earlobe

b. earlobe to xiphoid process

6. Add the measurements together 6. So that you will know the

and mark this total distance with a length of your insertion.
small piece of tape.
7. Inspect both of the patient’s 7. To be able to select the nostril
nostrils for patency. Have the patient that has the greater airflow.
blow nose if able.
8. Lubricate 2-4 inches of tube with 8. A squirt of Xylocaine jelly in
lubricant (preferably 2% Xylocaine). the nostril, and a spray of
This procedure is very uncomfortable Xylocaine to the back of the
for many patients. Choose the largest throat will help alleviate the
patent nostril and begin to pass the discomfort it is also helpful in
NGT through the nostril to the facilitating insertion
nasopharynx; direct the tube through
the nostril aiming down and back.
9. Once in the pharynx instruct the 9. To facilitate easier passage of
patient to swallow either mimicking the tube.
the action or by sipping on small
amounts of water. If awake and alert
have the patient place chin to chest
Introduce the tube until the selected
mark (indicated by the tape) is
reached.

10. Verify NGT placement in the 10. To ascertain correct

stomach by two of the following: placement of the tube

• Chest X-ray

• Aspirating gastric contents with

the irrigation syringe
 • While listening over the
epigastrum with a stethoscope
quickly instill a 30cc air bolus
with the irrigation syringe. Air
entering the stomach will
produce a “whooshing” sound.
• Ask the patient to hum or talk.
Coughing, cyanosis or choking
may indicate that the NGT has
passed through the larynx.

• Place the open end of the NGT in

a cup of water. Persistent
bubbling may indicate that the
NGT has passed through the
larynx.
11. If unable to positively confirm 11. To be sure that the tube is
that the NGT has been placed is in inserted correctly.
the stomach the tube must be
removed immediately and re-
attempted.
12. Once confirmed for placement, 12. Taping in this manner
secure the NGT by placing one end of prevents the tube from pressing
tape on from the bridge to the tip of against and irritating the edge of
the nose and the other end wrapped the nostril.
around the tube itself. If possible the
nose should be clean and prepped
prior to securing with tincture of
benzoin.
13. Clamp or connect the NGT as 13. This will prevent gastric
desired. If a Salem sump tube is contents from leaking back
utilized it is important to remember through vent lumen.
that the blue pigtail must be kept at
the level of the fluid in the patient’s
stomach.
14. Secure the tube to the client’s 14. The tube is attached to
gown prevent it from dangling and
pulling.
• Loop an elastic band around
the end of the tubing, and
attach the elastic band to the
gown with a safety pin or
• Attach a piece of adhesive
tape to the tube, and pin the
tape to the gown.

Complications

The main complications of NGT insertion include aspiration and tissue

trauma. Placement of the catheter can induce gagging or vomiting, therefore
suction should always be ready to use in the case of this happening. More
serious complications include esophageal perforation, aspiration,
pneumothorax, and, rarely, intracranial placement.

Practice Questions
Kindly answer the following questions before proceeding to
your Post Test

1. What is the size of the Nasogastric tubes used for adults?

____________________.
2. Why is washing of hands or observing other appropriate infection
control procedures necessary before the performance of the
procedure?
_______________________________________________________________________
_________________________________________.
3. This will prevent gastric contents from leaking back through the vent
lumen._________________________________________________________________
__________________________________.

Feedback

Did you say something like?

1. The size of the NGT for adults is FR 16 or 18.
2. Washing of hands and observing other appropriate infection control
procedures is necessary before the performance of the procedure is to
prevent cross-contamination from secretions between the nurse and
the patient, and vice versa.
3. Clamping or connecting the NGT will prevent gastric contents from
leaking back through the vent lumen.
Post Test

1. What is the other name of Enteral Nutrition?_________________________.

2. What is the normal pH of the stomach that will determine the correct
placement of the tube?____________________.
3. The commonly use nasogastric tube is called ___________________.
4. By inserting this tube, you are gaining access to the stomach and its
contents. What do you call that tube?
5. Excessive ____________________ or ___________________ during placement
including coughing or gagging may potentiate cervical injury.
6.10. Give me 5 Equipments used in NGT insertion
11.13. Give me 3 ways on how you could verify the tube placement.
14.15. Give me 2 serious complications of NGT insertion.

Answers to Post Test.

1. Total enteral nutrition (TEN)
2. pH 5.5 or below
3. Levin Tube
4. Nasogastric Tube
5. Manipulation or movement by the patient
6.10. This includes
• Nasogastric tube
• Viscous lidocaine 2%
• Oral analgesic spray (Benzocaine spray or other)
• Oral syringe, 12 mL
• Glass of water with a straw
• Water-based lubricant
• Toomey syringe, 60 mL
 • Tape
• Emesis basin or plastic bag
• Wall suction, set to low intermittent suction
• Suction tubing and container

11-13. Verify NGT placement in the stomach by two of the following:

• Chest X-ray
• Aspirating gastric contents with the irrigation
syringe
• While listening over the epigastrum with a
stethoscope quickly instill a 30cc air bolus with the
irrigation syringe. Air entering the stomach will
produce a “whooshing” sound.
• Ask the patient to hum or talk. Coughing, cyanosis
or choking may indicate that the NGT has passed
through the larynx.
• Place the open end of the NGT in a cup of water.
Persistent bubbling may indicate that the NGT has
passed through the larynx.

14-15. Serious complications includes

• esophageal perforation,
• aspiration,
• pneumothorax,
• and, rarely, intracranial placement.