Nasogastric tube insertion steps

Nasogastric Intubation:

Indications: 1. Removing stomach contents A. Diagnostic GI bleeding Penetrating or blunt trauma B. Therapeutic Paralytic ileus Gastric dilatation Intestinal obstruction Persistent vomiting Removal of toxins and pill fragments Heating or cooling for temperature abnormalities C. Prophylactic

Decompression prior to abdominal surgery or peritoneal lavage Prevention of aspiration in multiple trauma 2. Instillation of materials Medications, feedings, contrast, charcoal Contraindications:

Loss of integrity of cribriform plate (midface fracture) Esophageal stricture Comatose patients without airway protection Penetrating neck trauma

(Note: varices are not a contraindication) Equipment: 1. 2. 3. 4. 5. Salem sump tube of appropriate size Suction apparatus Cup of water with straw (for cooperative patients) 2% Lidocaine gel, small syringe Lubricant 6. 7. Procedure: 1. Position patient: fully sitting if awake; supine wlneck flexion if comatose 2. Inspect nares for obstruction; apply nasal decongestant and anesthetic to nasal mucosa, pharynx 3. Estimate tube insertion length: ear-nose-xiphoid, mark wltape (Fig. 1) 4. Pass lubricated tube along floor of nose (Fig. 2) Tape, benzoin Nasal decongestant (optional)

5. Ask patient to sip water, advance tube quickly with swallowing 6. Confirm placement by auscultation over stomach, aspiration of gastric contents, or by x-ray in comatose patients. Nasogastric tube insertion step-by-step: 1. 2. 3. 4. 5. 6. 7. patient in high fowlers towel on patients chest and emesis basin within reach wipe nasal bridge with alcohol swab stand on pts right side if right handed Select nostril with greatest air flow Measure tube distance tip of nose to earlobe, then to xiphoid process mark length on tube with tape prior to insertion to prevent inserting greater length than needed 8. lubricate 7.5-10cm of tube 9. instruct pt to initially extend neck back against pillow 10. insert tube gently and slowly through nares 11. aim down to patients ear 12. if resistance is felt do not force tube 13. if resistance is felt try to rotate tube to advance 14. if resistance still met, withdraw tube, allow pt to rest, then lubricate again and attempt in other nare 15. when tube reaches just above oropharynx, instruct pt to flex head forward, take a small sip of water and swallow 16. advance tube 2.5-5cm with each swallow 17. if pt begins to cough, gag or choke withdraw tube slightly and stop advancement, instruct pt to breath and take sips of water 18. Check placement

instruct pt to talk inspect posterior pharynx for coiled tube attach catheter tip syringe to end of tube and aspirate contents check colour and pH order X ray to check tube placement

OBJECTIVE: To check if the patient can tolerate oral feeding. CONTRAINDICATION: Continuing need for feeding/suction. AFTER CARE: a. Discard the disposasble equipment used. b. Wash your hands. c. Position the patient in a comfortable or in his desired position. CHARTING: a. Record date of removal of nasogastric tube. b. Record clients response. c. Record measurement of drainage. NURSING ALERT: Removal is easier with the patient in semiFowlers position. EQUIPMENT: 1. Tissues 2. Plastic disposable bag 3. Bath towel or disposable pad 4. Clean disposable glove ACTION 1. Check physicians order for removal of nasogastric tube. Rationale: Ensures correct implementation of physicians order. 2. Explain procedure to client. Rationale: Explanation facilitates client cooperation.. 3. Gather equipment. Rationale: Provides for organized approach to task. 4. Wash your hands. Don clean disposable glove on hand that will remove tube. Rationale: Handwashing deters the spread of microorganisms. Gloves protect hand from contact with abdominal secretions. 5. Discontinue suction and separate tube from suction. Unpin tube from cleints gown and carefully remove adhesive tape from bridge of nose. Rationale: Allows for unrestricted removal of nasogastric tube.

6. Place towel or disposable pad across clients chest. Hand tissues to client. Rationale: Protects client from contact with gastric secretions. Tissues are necessary if client wishes to blow his nose when tube is removed. 7. Instruct client to take a deep breath and hold it. Rationale: Prevents accidental aspiration of any gastric secretions in tube. 8 Clamp tube with fingers. Quickly and carefully remove tube while client holds his breath. Rationale: Minimizes trauma and discomfort for client. Clamping prevents any drainage of gastric contents in tube. 9 Place tube in disposable plastic bag. Remove glove and place in bag. Rationale: Prevents contamination with any microorganisms. 10. Offer mouth care to client and make client feel comfortable. Rationale: Provides comfort. 11. Measure nasogastric drainage. Remove all equipment and dispose according to agency policy. Wash your hands. Rationale: Measuring nasogastric drainage provides for accurate recording of output. Proper disposal deters spread of microorganisms. 12. Record removal of nasogastric tube, clients response, and measurement of drainage. Rationale: Facilitates documentation and provides for comprehensive care.

OBJECTIVE: To ensure the patency of the nasogastric tube. INDICATION: Stomach contents fail to flow through tube. CONTRAINDICATION: Some tubes are maintained by airflow, not normal saline solution.

NURSING ALERT: Connect proper end (main lumen) of double lumen tube to suction. The short lumen is an airway, not a suctiondrainage tube. With double-lumen tube, if main lumen is probably blocked, clear the main lumen, then inject up to 60 cc of air through the short lumen above the level of the stomach where the end of the main lumen is located. EQUIPMENT: 1. Nasogastric tube connected to continuous or intermittent suction. 2. Irrigation or Toomey syringe and container for irrigating solution. 3. Normal saline for irrigation. 4. Disposable pad or bath towel 5. Disposable gloves (optional) 6. Stethoscope 7. Clamp ACTION 1. Check physicians order for irrigation. Explain procedure to client. Rationale: Clarifies schedule and irrigating solution. An explanation encourages client cooperation and reduces apprehension. 2. Gather necessary equipment. Check expiration dates on irrigating saline and irrigation set. Rationale: Provides for organized approached to task. Agency policy dictates safe interval for reuse of equipment. 3. Wash your hands. Rationale: Handwashing deters the spread of microorganisms. 4. Assist client to semi-Fowlers position unless this is contraindicated. Rationale: Minimizes risk of aspiration. 5. Check placement of NG tube; a. Attach Asepto or Toomey syringe to the end of tube and aspirate gastric contents. Rationale: The tube is in the stomach if its contents can be aspirated. b. Place 10mL-50ml of air in syringe and inject into the tube. Simultaneously, auscultate over the epigastric area with a stethoscope.

Rationale: A whoosing sound can be heard when the air enters the stomach through the tube. c. Ask client to speak. Rationale: If tube is misplaced in trachea, client will not be able to speak. 6. Clamp suction tubing near connection site. Disconnect NG tube from suction apparatus and lay on disposasble pad or towel. Rationale: Protects client from leakage of NG drainage. 7. Pour irrigating solution into container. Draw up 30 ml of saline (or amount ordered by physician) into syringe. Rationale: Delivers measured amount of irrigant through NG tube. Saline compensates for electrolytes lost through NG drainage. 8 Place tip of syringe in NG tube. Hold syringe upright and gently insert the irrigant (or allow solution to flow in by gravity if agency or physician indicates). Do not force solution into NG tube. Rationale: Position of syringe prevents entry of air into stomach. Gentle insertion of saline (or gravity insertion) is less traumatic to gastric mucosa. 9 If unable to irrigate tube, reposition client and attempt irrigation again. Check with physician if repeated attempts to irrigate tube fail. Rationale: Tube may be positioned against gastric mucosa making it difficult to irrigate. 10. Withdraw or aspirate fluid into syringe. If no return, inject 20 ml of air and aspirate again. Rationale: Inject of air may reposition the end of tube. 11. Reconnect NG tube to suction. Observe movement of solution or drainage. Rationale: Determine patency of NG tube and correct operation of suction apparatus. 12. Measure and record amount and description of irrigant and return solution. Rationale: Irrigant placed in NG tube is considered intake: solution returned is recorded as output.

13. Rinse equipment if it will be reused. Rationale: Promotes cleanliness and prepares equipment for next irrigation. 14. Wash your hands Rationale: Handwashing deters the spread of microorganisms. 15. Record irrigation procedure, description of drainage and clients response. Rationale: Facilitates documentation of procedure and provides for comprehensive care.