Nasogastric Intubation

EQUIPMENTNasogastric (NG) tube—usually single-lumen Levin or double-lumen Salem sump tubeWater-soluble lubricantSuction equipment if orderedClamp for tubingTowel, tissues, and emesis basinGlass of water and strawTincture of benzoinHypoallergenic tape: ½ inch and 1 inchBio-occlusive transparent dressingIrrigating set with 20-mL syringe or a 50-mL catheter-tip syringeStethoscopeTongue bladePenlightDisposable glovesNormal saline

PROCEDURENursing Action RationalePreparatory phase1.Ask the patient if he has ever had

nasal surgery, trauma, a deviated septum, or bleeding disorder.

1.Nasogastric tubes may be contraindicated in patients with nasopharyngeal or esophageal obstruction, severe uncontrolled coagulopathy, or severe maxillofacial trauma.

2.Explain procedure to the patient, and tell how mouth breathing, panting, and swallowing will help in passing the tube.

2. Improves comfort and compliance.

3.Place the patient in a sitting or high-Fowler's position; place a towel across chest.

3.Facilitates passage of tube into esophagus.

4.Determine with the patient what sign he might use, such as raising the index finger, to indicate “wait a few moments†� because of gagging or discomfort.

4.Provides a method of communication, which is reassuring to the patient.

5.Remove dentures; place emesis basin and tissues within the patient's reach.

5.Dentures may become loose and interfere with tube insertion.

6. Inspect the tube for defects; look for partially closed holes or rough

6. Irrigation and suction may be affected by defective tube.

edges.7.Place rubber tubing in ice-chilled

water for a few minutes to make the tube firmer. Plastic tubing may already be firm enough; if too stiff, dip in warm water.

7.A firm tube that is not too rigid will pass easiest, without causing trauma.

8.Determine the length of the tube needed to reach the stomach (see accompanying figure).

8.To prevent coiling of tube in stomach or tube ending in esophagus.

9.Have the patient blow nose to clear nostrils.

9.To facilitate passage through the nose.

10.

Inspect the nostrils with a penlight, observing for any obstruction. Occlude each nostril, and have the patient breathe. This will help determine which nostril is more patent.

   

11.

Wash your hands. Put on disposable gloves.

11.

To protect nurse from patient's secretions.

12.

Measure the patient's NEX (nose, earlobe, xiphoid), and mark the tube appropriately. Some tubes may be premarked to indicate length, but this may not correlate exactly with the measurement obtained.

12.

The measurement will help ensure that the end of tube reaches the stomach.

  a.

The distance from the nose to the earlobe is the first mark on the tube. This measurement represents the distance to the nasal pharynx.

  b.

When the tube reaches the xiphoid process (tip of the breast bone) a second mark is made on the tube. This measurement represents the length required to reach the stomach.

Performance phase1.Coil the first 3-4 inches (7-10 cm) of

the tube around your fingers.1.This curves tubing and facilitates

tube passage.2.Lubricate the coiled portion of the

tube with water-soluble lubricant. Avoid occluding the tube's holes with lubricant.

2.Lubrication reduces friction between the mucous membranes and tube and prevents injury to the nasal passages. Using a water-soluble lubricant prevents oil aspiration pneumonia if the tube

accidentally slips into trachea.3.Tilt back the patient's head before

inserting tube into nostril, and gently pass tube into the posterior nasopharynx, directing downward and backward toward the ear.

3.The passage of the tube is facilitated by following the natural contours of the body. The slower the advancement of the tube at this point, the less likelihood of putting pressure on the turbinates, which could cause pain and bleeding.

4.When tube reaches the pharynx, the patient may gag; allow patient to rest for a few moments.

4.Gag reflex is triggered by the presence of the tube.

5.Have the patient tilt head slightly forward. Offer several sips of water through a straw, or permit patient to suck on ice chips, unless contraindicated. Advance tube as patient swallows.

5.Flexed head position partially occludes the airway, and the tube is less likely to enter trachea. Swallowing closes the epiglottis over the trachea and facilitates passage of tube into the esophagus. Actually, when the tube passes the cricopharyngeal sphincter into the esophagus, it can be slowly and steadily advanced even if the patient does not swallow.

6.Gently rotate the tube 180 degrees to redirect the curve.

6.This prevents the tube from entering the patient's mouth.

7.Continue to advance tube gently each time the patient swallows.

7.Facilitates forward movement.

8. If obstruction appears to prevent tube from passing, do not use force. Rotating tube gently may help. If unsuccessful, remove tube and try other nostril.

8.Avoid discomfort and trauma to patient.

9. If there are signs of distress such as gasping, coughing, or cyanosis, immediately remove tube.

9.May have entered the trachea.

10.

Continue to advance the tube when the patient swallows, until the tape mark reaches the patient's nostril.

10.

This is the reference point where the tube was measured.

11.

To check whether the tube is in the stomach:

11.

 

  a.

Ask the patient to talk.   a.

If the patient cannot talk, the tube may be coiled in throat or passed through vocal cords.

  b.

Use the tongue blade and penlight to examine the

  b.

If the patient is choking or has difficulty breathing, the tube has

patient's mouth—especially an unconscious patient.

probably entered the trachea.

  c.

Attach a syringe to the end of the NG tube. Place a stethoscope over the left upper quadrant of the abdomen, and inject 10 to 20 cc of air while auscultating the abdomen.

  c.

Air can be detected by a “whooshing†� sound entering stomach rather than the bronchus. If belching occurs, the tube is probably in the esophagus.

  d.

Obtain aspirate with 30 to 60 mL syringe. If stomach contents cannot be aspirated, reposition the patient and repeat air insufflation. Attempt to aspirate again

  d.

If aspirate obtained, check for gastric placement indicators: ph ≤ 5 and gastric fluid characteristics of grassy green, clear and colorless, or brown.

  e.

X-rays may be done to confirm tube placement.

  e.

Consider X-ray confirmation of tube placement in patients with risk factors for malpositioning of tubes.

NURSING ALERT Never place the end of the tube in water while checking placement. If the tube is in the trachea, the patient could aspirate.NURSING ALERT Patient risk factors for malpositioned tubes include craniofacial trauma, reduced cough and gag reflexes, confusion, presence of endotracheal tube, decreased consciousness, and noncooperation at insertion.

12.

After tube is passed and the correct placement is confirmed, attach the tube to suction or clamp the tube.

12.

Clamping can be done using a clamp, plastic plug, or folding the tube over and slipping the bend into the tube end.

13.

Apply tincture of benzoin to the area where the tape is placed.

13.

This helps make the tube adhere, especially with diaphoretic patients.

14.

Anchor tube with: 14.

Prevents the patient's vision from being disturbed; prevents tubing from rubbing against nasal mucosa. This will ensure tape being secure. Do not tape to forehead, this could cause necrosis of the nostril.

  a.

Hypoallergenic tape; split lengthwise and only halfway, attach unsplit end of tape to nose, and cross split ends around tubing. Apply another piece of tape to bridge of nose.

  b.

Bio-occlusive transparent dressing where it exits the nose.

15.

Anchor the tubing to the patient's gown. Use a rubber band to make a slip-knot to

15.

To permit mobility of patient. This prevents tugging on the tube when the patient moves.

anchor the tubing to the patient's gown. Secure the rubber band to the patient's gown using a safety pin.

16.

Clamp the tube until the purpose for inserting the tube takes place.

16.

See #12.

17.

Attach the larger lumen of the Salem sump tube to suction equipment if ordered. Low continuous suction or high intermittent suction may be used with the Salem sump tube. If the Levin tube is used, low intermittent suction is recommended.

17.

To prevent gastric mucosal damage, if a vacuum forms and the tube adheres to the gastric wall.

Follow-up phase1.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 fluid.

2.To ensure the tube patency.

  a.

If the tube is a Salem sump, it will require periodic placing of 10-20 cc of air through the vent port (blue port or smaller lumen). Do not instill water into the vent, and, if the vent is draining fluid, instill air to clear it.

  b.

Check the Salem sump tube patency by placing the vent port next to your ear.

  b.

A soft hissing sound is heard if the tube is patent. If the port hangs downward and the tube backs up, stomach contents will spill over the patient.

3.Cleanse nares and provide mouth care every shift.

3.Promotes patient comfort and decreases risk of infection.

4.Apply petroleum jelly to nostrils as needed, and assess for skin irritation or breakdown.

4.To keep tissue soft and prevent crusting and skin breakdown.

5.Keep head of bed elevated at least 30 degrees.

5.To minimize gastroesophageal reflux.

6.Record the time, type, and size of tube inserted. Document

6.To ensure proper tube and placement at all times, and assist in evaluation of

placement checks after each assessment, along with amount, color, consistency of drainage.

tube effectiveness.