NASOGASTRIC TUBE

INSERTION and
FEEDING
HARLEY L. DELA CRUZ RN MAN
Instructor
2012
PLS READ FIRST CHAPTER 36
BRUNNER AND SUDDARTHS TEXT
BOOK MS NURSING 7
TH
EDITION
NASOGASTRIC TUBE
The nasogastric (NG) tube is passed through the nose,
past the throat and into the stomach. This type of tube
permits the patient to receive nutrition through a tube
feeding using the stomach as a natural reservoir for
food. Another purpose of a NG tube may be to
decompress or to drain unwanted uid and air from
the stomach. This application would be used, for
example, to allow the intestinal tract to rest and
promote healing after bowel surgery. The NG tube can
also be used to monitor bleeding in the
gastrointestinal (GI) tract, to remove un-desirable
substances (lavage) such as poisons, or to help treat
an intestinal obstruction.
NASOGASTRIC TUBE
TYPES OF PROCEDURES
GASTRIC GAVAGE

GASTRIC LAVAGE


Indications
Diagnostic
Evaluation of upper gastrointestinal (GI)
bleed (ie, presence, volume)
Aspiration of gastric fluid content
Identification of the esophagus and
stomach on a chest radiograph
Administration of radiographic contrast
to the GI tract
Indications
Therapeutic
Gastric decompression, including maintenance
of a decompressed state after endotracheal
intubation, often via the oropharynx
Relief of symptoms and bowel rest in the setting
of small-bowel obstruction
Aspiration of gastric content from recent
ingestion of toxic material
Administration of medication
Feeding
Bowel irrigation
Contraindications
Absolute contraindications
Severe midface trauma
Recent nasal surgery

Relative contraindications
Coagulation abnormality
Esophageal varices or stricture
Recent banding or cautery of
esophageal varices
Alkaline ingestion
EQUIPMENTS
EQUIPMENTS
Nasogastric (polyurethane) tube of
appropriate size (818 French)
Stethoscope
Small basin lled with ice or warm water
(optional)
Water-soluble lubricant
Normal saline solution (for irrigation only)
Tongue blade
Asepto bulb syringe or Toomey syringe (20
50 mL)
Flashlight
Nonallergenic tape (1wide)
Tissues
EQUIPMENTS
Tissues
Glass of water with straw
Topical anesthetic (lidocaine spray or gel)
(optional)
Clamp
Suction apparatus (if ordered)
Bath towel or disposable pad
Emesis basin
Safety pin and rubber band
Nonsterile disposable gloves
Tincture of benzoin or skin adhesive
pH paper
TYPES OF NASOGASTRIC
TUBES
The Levin Tube -is a one-lumen nasogastric
tube
TYPES OF NASOGASTRIC
TUBES
The Salem-Sump Tube.

This tube is a two-lumen
piece of equipment.

It has a drainage lumen and
a smaller secondary tube
that is open to the
atmosphere.
TYPES OF NASOGASTRIC
TUBES
The Miller-Abbott Tube.

This tube is also a two-lumen
nasogastric tube.

There is a rubber balloon at
the tip of one tube; the
other tube has holes near
its tip.
TYPES OF NASOGASTRIC
TUBES
The Cantor Tube - has one lumen and a bag
on the end.
Sengstaken-Blakemore Tube


SIZES

Adult - 16-18F


Pediatric - In pediatric patients, the
correct tube size varies with the
patients age.
Size FG-8 FG-10 FG-12 FG-14 FG-16 FG-18 FG-20
Colour Code Blue Black White Green Orange Red Yellow
Infection Control
Hand Washing
Wear a set of gloves
Wearing face and eye protection
Wear disposable apron.
Assessment
Assess the patency of the patients nares by asking
the patient to occlude one nostril and breathe
normally through the other. Select the nostril through
which air passes more easily. Also, assess the
patients history for any recent facial trauma, polyps,
blockages, or surgeries. Patients with facial fractures
or facial surgeries present a higher risk for
misplacement into the brain. Many institutions require
a physician to place NG tubes in these patients.
Inspect the abdomen for distention and firmness;
auscultate for bowel sounds or peristalsis and palpate
the abdomen for distention and tenderness. If the
abdomen is distended, consider measuring the
abdominal girth at the umbilicus to establish a
baseline.
Possible nursing diagnoses may
include:
Imbalanced Nutrition, Less than
Body Requirements
Risk for Aspiration
Impaired Swallowing
Acute Pain
Decient Knowledge
Risk for Disturbance in Body Image
Nausea
NURSING RESPONSIBILITY
Inserting and removing the tube
Assessing correct placement
Securing the tube
Meeting patient comfort needs
Monitoring patient responses
IMPLEMENTATION
Verify for physician order.
Identify Client & Introduce yourself
Explain the procedure
Assemble the Materials needed

IMPLEMENTATION
Explain the procedure, benefits, risks,
complications, and alternatives to
the patient or the patient's
representative.
Examine the patients nostril for septal
deviation. To determine which nostril
is more patent, ask the patient to
occlude each nostril and breathe
through the other.
POSITION
Position the patient in a High Fowlers
position.
Adult
Measure from
the tip of the
nose, around the
ear, and down to
the xyphoid
process.
MEASUREMENT
Infant
Measure from
the tip of the
nose, around the
ear and down to
the umbilicus.
MEASUREMENT
INSERTION
Lubricate the distal end of the Tube
INSERTION
After selecting the appropriate
nostril, ask patient to slightly
hyperextend head back against the
pillow. Gently insert the tube into the
nostril while directing the tube
upward and backward along the oor
of the nose .Patient may gag when
tube reaches pharynx. Provide
tissues for tearing or watering of
eyes. Offer comfort and reassurance
to the patient.
INSERTION
When pharynx is reached, instruct patient to
touch chin to chest. Encourage patient to sip
water through a straw or swallow even if no
uids are permitted. Advance tube in
downward and backward direction when patient
swallows. Stop when patient breathes. If
gagging and coughing persist, stop advancing
the tube and check placement of tube with
tongue blade and ashlight. If tube is curled,
straighten the tube and attempt to advance
again. Keep advancing tube until pen marking
is reached. Do not use force. Rotate tube if it
meets resistance.
INSERTION
Instruct the Patient to drink while
the tube is inserted
INSERTION
Discontinue procedure and
remove tube if there are signs of
distress, such as gasping,
coughing, cyanosis, and inability
to speak or hum.

CHECKING FOR PLACEMENT
While keeping one hand on tube or
temporarily securing with tape, determine
that tube is in patients stomach:

a. Attach syringe to end of tube and aspirate
a small amount of stomach contents.
Visualize aspirated contents, checking for color
and consistency.

The tube is in the stomach if its contents
can be aspirated:pH of aspirate can then
be tested to determine gastric placement.
If unable to obtain specimen, reposition
the patient and ush the tube with 30 mL
of air. This action may be necessary
several times. Current literature
recommends that the nurse ensures
proper placement of the NG tube by
relying on multiple methods and not on
one method alone.
Visualize aspirated contents, checking for
color and consistency.
Gastric uid can be green with particles, off
white, or brown if old blood is present.
Intestinal aspirate tends to look clear or straw-
colored to a deep golden-yellow color.
Also, intestinal aspirate may be greenish-
brown if stained with bile.
Respiratory or tracheobronchial uid is usually
off-white to tan and may be tinged with
mucus.
A small amount of blood-tinged uid may be
seen immediately after NG insertion.

b. Auscultation of air
insufflated through
the tube
CHECKING FOR PLACEMENT
c. Immersion of the
Proximal end of in a
glass of water.
d. Aspiration of fluid from the tube,
with pH testing of the aspirate.
pH < 5 GIT
pH > 6 - Respiratory
CHECKING FOR PLACEMENT
Current research demonstrates that
the use of pH is predictive of correct
placement. The pH of gastric
contents is acidic (less than 5.5). If
patient is taking an acid-inhibiting
agent, the range may be 4.0 to 6.0.
The pH of intestinal uid is 7.0 or
higher. The pH of respiratory uid
is 6.0 or higher. This method will
not effectively differentiate between
intestinal uid and pleural uid.
e. Chest X-ray
CHECKING FOR PLACEMENT
f. NG OPTIMIZER
SECURE THE TUBE
Anchor the tube securely to the nose and
cheek - keeping it out of the patients field
of vision.
SECURE THE TUBE
Apply tincture of benzoin or other skin
adhesive to tip of nose and allow to dry.
Secure tube with tape to patients nose:
a. Cut a 4 piece of tape and split bottom 2
or use packaged nose tape for NG tubes.
b. Place unsplit end over bridge of patients
nose.
c. Wrap split ends under tubing and up and
over onto nose. Be careful not to pull tube
too tightly against nose.

Clamp tube and cap or attach tube to
suction according to the physicians
orders.
Secure tube to patients gown by
using rubber band or tape and safety
pin. For additional support, tube can
be taped onto patients cheek using a
piece of tape. If double-lumen
tube (eg, Salem sump) is used,
secure vent above stomach level.
Attach at shoulder level.

Assist with or provide oral hygiene at
every 2- to 4-hour interval. Lubricate
the lips generously and clean nares and
lubricate as needed. Offer analgesic
throat lozenges or anesthetic spray for
throat irritation if needed.
Remove all equipment, lower the bed,
and make the patient comfortable.
Remove gloves and perform hand
hygiene.

Unexpected Situations and
Associated Interventions
As tube is passing through pharynx,
patient begins to retch and gag: This is
common during placement of an NG tube.
Ask the patient if he/she wants the nurse
to stop the procedure, allowing the patient
to gain composure from the gagging
episode. Continue to advance tube if the
patient relates that he/she agrees. Have
the emesis basin nearby incase patient
begins to vomit.
Unexpected Situations and
Associated Interventions
The nurse is unable to pass the
tube after trying a second time
down the one nostril: If the
patients condition permits, inspect
the other nostril and attempt to pass
the nasogastric tube down this
nostril. If unable to pass down this
nostril, consult another health
professional.

Unexpected Situations and
Associated Interventions
As tube is passing through pharynx,
patient begins to cough and shows signs
of respiratory distress: Stop advancing the
tube! The tube is most likely entering the
trachea. Pull tube back into nasal area. Support
patient as he/she regains normal breathing
ability and composure. If patient feels that
he/she can tolerate another attempt, ask
patient to keep chin on chest and swallow as
tube is advanced to help prevent the tube from
entering thetrachea. Begin to advance tube,
watching for any signs of respiratory distress.
Unexpected Situations and
Associated Interventions
No gastric contents can be
aspirated: If patient is comatose,
check oral cavity. If tube is in gastric
area, small air boluses may need to
be given until gastric contents can be
aspirated.
Special Nursing Considerations
Measure tube from tip of nose to ear
lobe and from ear lobe to xiphoid
process. Add 8to 10for intestinal
placement. Mark tubing at desired
point.
Place patient on his or her right side.
Nasointestinal tube is usually placed in
the stomach and allowed to advance
through peristalsis through the pyloric
sphincter (may take up to 24 hours).
Special Nursing Considerations
Administer medications to enhance
GI motility, such as metoclopramide
(Reglan), if ordered.
Test pH of aspirate when tube has
advanced to marked point to conrm
placement in intestine. Conrm
position by radiograph. Secure with
tape once placement is conrmed.
COMPLICATIONS
Minor complications
- Nose Bleeds,Sinusitis, and sore throat

More significant complications
- Erosion of the nose where the tube is
anchored, esophageal perforation,
pulmonary aspiration, a collapsed lung, or
intracranial placement of the tube.
DOCUMENTATION
Date and time of procedure
Indication for insertion
Type of tube used
Distance tube inserted (if appropriate)
The nature of the aspirate
Methods used to check location of the
tube insertion
Any procedural comments
ADMINISTERING A TUBE FEEDING
Feeding can be provided on an intermittent or
continuous basis. If the order calls for
continuous feeding, an external feeding pump
is needed to regulate the ow of formula.
Intermittent feedings are delivered at regular
intervals, using gravity for instillation or a
feeding pump to administer the formula over a
set period of time. Intermittent feedings might
also be given as a bolus, using a syringe to
instill the formula quickly in one large amount.
Goal: The patient will receive the tube feeding
without complaints of nausea or episodes of
vomiting.


Transabdominal tube feeding
and care

A percutaneous endoscopic
gastrostomy (PEG) or (PEJ)
jejunostomy tube can be inserted
endoscopically without the need for
laparotomy or general anesthesia.
Used for nutrition, drainage, and
decompression.
Contraindications to endoscopic
placement
Obstruction
Previous gastric surgery
Morbid obesity
Ascites
Gastrostomy Feeding Tube
Jejunostomy Feeding Tube
Gastrojejunostomy Feeding Tube
Nursing care
Providing skin
care at the
tube site
Maintaining
the feeding
tube
Administering
Feeding
Monitoring
Patient
Response
Adjusting
Feeding
schedules
Equipment: NGT Feeding

o Feeding formula
120 ml of water
4 x 4 gauze pads
Soap, mouthwash, toothpaste, or mild salt solution
Skin protectant / 4 x 4 gauze pads
Hypoallergenic tape
Gravity drip administration bags
Gloves /Alcohol preps /Disposable pad or towel
Asepto or Toomey syringe
Enteral feeding pump (if ordered)
Rubber band /Clamp (Hoffman or buttery)
IV pole
pH paper
Preparation of Equipment
Always check the expiration date on commercially
prepared feeding formulas.
If the formula has been prepared by the dietitian or
pharmacist, check the preparation time and date.
Discard any opened formula thats more than 1 day
old.
Commercially prepared administration sets and
enteral pumps allow continuous formula
administration.

ASSESSMENT
Assess abdomen by inspecting for presence of
distention, auscultating for bowel sounds, and
palpating the abdomen for rmness or tenderness. If
the abdomen is distended, consider measuring the
abdominal girth at the umbilicus. If the patient reports
any tenderness or nausea, exhibits any rigidity or
rmness of the abdomen, and if there is an absence of
bowel sounds, confer with physician before
administering the tube feeding. Assess for patient
and/or family understanding if appropriate for the
rationale for the tube feeding and address any
questions or concerns expressed by the patient and
family members. Consult physician if need for further
explanation.
NURSING DIAGNOSIS
Imbalanced Nutrition, Less than
Body Requirements
Risk for Aspiration
Decient Knowledge
Risk for Impaired Social Interaction
Risk for Alteration in Nutrition
Risk for Body Image Disturbance.
IMPLEMENTATION
1. Identify the patient.
2. Explain the procedure to the patient and
why this intervention is needed. Raise the
bed. Pull the patients bedside curtain.
Perform key abdominal assessments as
described above.
3. Assemble equipment. Check amount,
concentration, type, and frequency of tube
feeding on patients chart. Check expiration
date of formula.
4. Perform hand hygiene. Put on No gloves.

5. Position patient with head of bed elevated at
least 30 to 45 degrees or as near normal
position for eating as possible.
6. Unpin tube from patients gown. Check to see that
the NG tube is properly located in the stomach,
by first instilling air, then aspirate for gastric
contents. At times, due to the tendency of small-
bore tubes to collapse upon aspiration, several
attempts may be necessary to aspirate gastric
contents. After repeated instillations of 30 mL of air,
accompanied by repositioning the patient, if unable
to aspirate gastric contents, the tube placement
should be checked by radiograph verified by
physicians order. Check the pH
7. After multiple steps have been taken to
ensure that the feeding tube is located in the
stomach or small intestine, aspirate all
gastric contents with a syringe and
measure to check for the residual
amount of feeding in the stomach. Flush
tube with 30 mL of water for irrigation.
Proceed with feeding if amount of residual
does not exceed agency policy or physicians
guideline. Disconnect syringe from tubing and
cap end of tubing while preparing the formula
feeding equipment. Remove gloves.
8. Put on gloves before preparing, assembling
and handling any part of the feeding system.

9. Administer feeding.
When Using a Feeding Bag (Open System)
a. Hang bag on IV pole and adjust to about
12 above the stomach. Clamp tubing.
b. Check the expiration date of the formula.
Cleanse top of feeding container with a
disinfectant before opening it. Pour formula
into feeding bag and allow solution to
run through tubing. Close clamp.
c. Attach feeding setup to feeding tube, open
clamp, and regulate drip according to
physicians order, or allow feeding to run in
over 30 minutes.

d. Add 30 to 60 mL (12 oz) of water for
irrigation to feeding bag when feeding
is almost completed and allow it to run
through the tube.
e. Clamp tubing immediately after water has
been instilled. Disconnect from feeding tube.
Clamp tube and cover end with cap.


When Using a Large Syringe (Open
System)
a. Remove plunger from 30- or 60-mL syringe.
b. Attach syringe to feeding tube, pour
premeasured amount of tube feeding into
syringe, open clamp, and allow food to enter
tube. Regulate rate, fast or slow, by
height of the syringe. Do not push
formula with syringe plunger.
c. Add 30 to 60 mL (12 oz) of water for
irrigation to syringe when feeding is
almost completed, and allow it to run
through the tube.


d. When syringe has emptied, hold syringe
high and disconnect from tube. Clamp tube
and cover end with cap.
10. Observe the patients response during
and after tube feeding and assess the
abdomen at least once a shift.
11. Have patient remain in upright
position for at least 1 hour after
feeding.
12. Wash and clean equipment or replace
according to agency policy. Remove gloves
and perform hand hygiene.

When the feeding finishes, flush the
feeding tube with 30 to 60 ml of
water to maintain patency and
provide hydration.
Cap the tube to prevent leakage.
Rinse the feeding administration set
thoroughly with hot water to avoid
contaminating subsequent feedings.
Allow it to dry between feedings.
Documentation
Type of nasogastric tube or gastrostomy/jejunostomy
Record tube length in inches or centimeters
Document the aspiration of gastric contents and pH
and bilirubin of the gastric contents when
intermittent feeding is used. Note the components of
the abdominal assessment, such as observation of
the abdomen, presence of distention or rmness, and
presence of bowel sounds. Include subjective data
from the patient such as abdominal pain or nausea or
any other patient response. Record the amount of
residual volume that was obtained. Document the
position of the patient, the type of feeding, and the
method and the amount of feeding. Include any
relevant patient teaching.
Follow up phase
1. Assure the patient that most
discomfort he feels will lessen as he
gets used to the tube.
2. Irrigate the tube at regular intervals
(every 2 hours unless otherwise
indicated) with small volumes of
prescribed fluid34.
3. Cleanse nares and provide mouth
care every shift35.
4. Apply petroleum jelly to nostrils as
needed, and assess for skin irritation
or breakdown36.
5. Keep head of bed elevated at least
30 degrees37.
6. Record the time, type, and size of
tube inserted. Document placement
checks after each assessment, along
with amount, color, consistency of
drainage38.
Unexpected Situations and Associated
Interventions
Tube is found not to be in stomach or
intestine: Tube must be in stomach before feed-
ing. If tube is in esophagus, patient is at increased
risk for aspiration.
When checking for residue, nurse aspirates a
large amount: Before discarding or replacing
residue, check with physician and agency policy.
Replacing a large amount may increase patients
risk for vomiting and aspiration, while discarding a
large amount may increase patients risk for
metabolic alkalosis. At times, the physician will
order the nurse to replace half of the residue and
recheck in a set amount of time.
Patient complains of nausea after tube
feeding: Ensure that head of bed remains
elevated and that suction equipment is at bedside.
Check medication record to see if any antiemetics
have been ordered for patient. Consider notifying
the physician for an order for an antiemetic.
When attempting to aspirate contents, nurse
notes that tube is clogged: Most obstructions
are caused by coagulation of formula. Try using
warm water and gentle pressure to remove clog.
Carbonated sodas, such as Coca Cola, and meat
tenderizers have not been shown effective in
removing clogs in feeding tubes. Never use a
stylet to unclog tubes. Tube may have to be
replaced. To prevent clogs, ensure that adequate
flushing is completed after feedings.
NGT Removal
Equipments
- Towel/ tissues
- Disposable gloves
- Mouth hygiene materials
- 50-mL syringe (optional)
- Gloves
- Stethoscope
- Disposable plastic bag
- Normal saline solution for irrigation
(optional)
- Emesis basin


Procedure: Preparation
1. Make sure that gastric or small
bowel drainage is not excessive in
volume.
2. Make sure, by auscultation, that
audible peristalsis is present.
3. Determine whether the patient is
passing flatus; this indicates
peristalsis39.
4. Verify the health care provider's
order for removal.

Performance phase
1. Place a towel across the patient's
chest, and inform him that the tube
is to be withdrawn40.
2. Apply disposable gloves41.
3. Remove the tape from the patient's
nose.
4. Instruct the patient to take a deep
breath and hold it42.
5. Slowly, but evenly, withdraw tubing
and cover it with a towel as it
emerges43. (As the tube reaches the
nasopharynx, you can pull quickly.)
6. Provide the patient with materials
for oral care and lubricant for nasal
dryness44.
7. Dispose of equipment in appropriate
receptacle.
8. Document time of tube removal and
the patient's reaction.
9. Document tube removal and color,
consistency, and amount of drainage
in suction canister.
10. Continue to monitor the patient for
signs of GI difficulties45.
Documentation
Document assessment of the abdomen. If an
abdominal girth reading was obtained, record
this measurement. Document the removal of
the nasogastric tube from the naris where it
had been placed. Note if there is any
irritation to the skin of the naris. Record the
amount of NG drainage in the suction
container on the patients intake-and-output
record as well as the color of the drainage.
Record any pertinent teaching, such as
instruction to patient to notify nurse if he/she
experiences any nausea, abdominal pain, or
bloating.
Unexpected Situations and Associated
Interventions
Within 2 hours after NG tube removal,
patients abdomen is showing signs of
distention: Notify physician. Physician
may order nurse to replace NG tube.
Epistaxis occurs with removal of NG
tube: Occlude both nares until bleeding
has subsided. Ensure that patient is in
upright position. Document epistaxis in
patients medical record.



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