nasogastric tube insertion

NASOGASTRIC TUBE NASOGASTRIC TUBE INSERTIONINSERTION

(A SELF-INSTRUCTIONAL (A SELF-INSTRUCTIONAL PACKAGE)PACKAGE)

ByBy

Arianne L. Garcia, Arianne L. Garcia, RNRN

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Nasogastric Tube Nasogastric Tube InsertionInsertion

Overview

Definition

Indications

Procedure

Complications

Preparation/ Equipments

Contraindications

Post Test Actual Video

Comprehension Check 1

Comprehension Check 2

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

OverviewOverview

Enteral feedings are Enteral feedings are administered through administered through nasogastric and small-nasogastric and small-bore feeding tubes or bore feeding tubes or through gastrostomy or through gastrostomy or jejunostomy tubes.jejunostomy tubes.

OverviewOverview

DefinitionDefinition

Nasogastric tube Nasogastric tube is a tube is a tube that is passed through the nose that is passed through the nose and down through the and down through the nasopharynx and esophagus nasopharynx and esophagus into the stomach, abbreviated into the stomach, abbreviated as NGT. It is a flexible tube as NGT. It is a flexible tube made of rubber or plastic, and it made of rubber or plastic, and it has bidirectional potential.has bidirectional potential.

The word “nasogastric" is a The word “nasogastric" is a hybrid of the Latin “naso" from hybrid of the Latin “naso" from "nasus" for nose or snout and "nasus" for nose or snout and the Greek “gastric" from the Greek “gastric" from "gaster" meaning the paunch or "gaster" meaning the paunch or belly. The term "nasogastric" belly. The term "nasogastric" was coined in 1942.was coined in 1942.A commonly used NGT is the A commonly used NGT is the Levin tubeLevin tube

DefinitionDefinition

IndicationsIndications

A person may need a stomach A person may need a stomach tube inserted to: tube inserted to: •empty the stomach after a empty the stomach after a drug overdose or accidental drug overdose or accidental poisoningpoisoning•drain the stomach after major drain the stomach after major trauma, so the person can't trauma, so the person can't inhale stomach contents into inhale stomach contents into the lungs the lungs

•treat malnutrition by giving treat malnutrition by giving feedings through the tube. Tube feedings through the tube. Tube feeding is also used when a person feeding is also used when a person is unable to eat normally, such as is unable to eat normally, such as after a stroke after a stroke •keep the stomach relaxed after keep the stomach relaxed after major surgery to the abdomen, such major surgery to the abdomen, such as an abdominal exploration as an abdominal exploration •prevent distension of the stomach prevent distension of the stomach when the person has a bowel when the person has a bowel obstructionobstruction

IndicationsIndications

ContraindicationsContraindications

•Patients with sustained head trauma, maxillofacial Patients with sustained head trauma, maxillofacial injury, or anterior fossa skull fracture. Inserting a NGT injury, or anterior fossa skull fracture. Inserting a NGT blindly through the nose has potential of passing through blindly through the nose has potential of passing through the criboform plate, thus causing intracranial penetration the criboform plate, thus causing intracranial penetration of the brain.of the brain.•Patients with a history of esophageal stricture, Patients with a history of esophageal stricture, esophageal varices, alkali ingestion at risk for esophageal esophageal varices, alkali ingestion at risk for esophageal penetration.penetration.•Comatose patients have the potential of vomiting during Comatose patients have the potential of vomiting during a NG insertion procedure, thus require protection of the a NG insertion procedure, thus require protection of the airway prior to placing a NGT.airway prior to placing a NGT.

Caution should be utilized when passing a NGT in a Caution should be utilized when passing a NGT in a patient with suspected cervical spine injury. patient with suspected cervical spine injury. •Excessive manipulation or movement by the patient Excessive manipulation or movement by the patient during placement including coughing or gagging may during placement including coughing or gagging may potentiate cervical injury. potentiate cervical injury. •Manual stabilization of the head is required during the Manual stabilization of the head is required during the procedure.procedure.

ContraindicationsContraindications•Patients with sustained head trauma, Patients with sustained head trauma, maxillofacial injury, or anterior fossa skull maxillofacial injury, or anterior fossa skull fracture. Inserting a NGT blindly through fracture. Inserting a NGT blindly through the nose has potential of passing through the nose has potential of passing through the criboform plate, thus causing the criboform plate, thus causing intracranial penetration of the brain.intracranial penetration of the brain.•Patients with a history of esophageal Patients with a history of esophageal stricture, esophageal varices, alkali stricture, esophageal varices, alkali ingestion at risk for esophageal ingestion at risk for esophageal penetration.penetration.•Comatose patients have the potential of Comatose patients have the potential of vomiting during a NG insertion procedure, vomiting during a NG insertion procedure, thus require protection of the airway prior thus require protection of the airway prior to placing a NGT.to placing a NGT.

ContraindicationsContraindications

Caution should be utilized when Caution should be utilized when passing a NGT in a patient with passing a NGT in a patient with suspected cervical spine injury. suspected cervical spine injury. •Excessive manipulation or Excessive manipulation or movement by the patient during movement by the patient during placement including coughing or placement including coughing or gagging may potentiate cervical gagging may potentiate cervical injury. injury. •Manual stabilization of the head Manual stabilization of the head is required during the procedure.is required during the procedure.

Comprehensive Test 1Comprehensive Test 1

Answer the following Multiple Choice Questions. Answer the following Multiple Choice Questions. Read each question carefully then just click on the Read each question carefully then just click on the

letter you think would be the right answer.letter you think would be the right answer.

Question # 1

Question # 2

Question # 3


Question #1Question #1

It is provided when the client is It is provided when the client is unable to ingest foods or the upper unable to ingest foods or the upper gastrointestinal tract is impaired and the gastrointestinal tract is impaired and the transport of food to the small intestine is transport of food to the small intestine is interrupted.interrupted.

a.a. TENTENb.b. NineNine


The commonly used NGT is called The commonly used NGT is called ____________?____________?

a.a. Levis TubeLevis Tubeb.b. Levin TubeLevin Tube



NGT NGT treat _________ by giving feedings through treat _________ by giving feedings through the tube.the tube.

a.a. Obesity Obesity b.b. MalnutritionMalnutrition


EquipmentsEquipments

Nasogastric tubeNasogastric tube

Viscous lidocaine 2%Viscous lidocaine 2%

Oral analgesic spray Oral analgesic spray (Benzocaine)(Benzocaine)

Oral syringe, 12 mLOral syringe, 12 mL

Glass of water with a strawGlass of water with a straw

Water-based lubricantWater-based lubricant

Toomey syringe, 60 mLToomey syringe, 60 mL

TapeTape

Emesis basin or plastic bagEmesis basin or plastic bag

Wall suction, set to low Wall suction, set to low intermittent suctionintermittent suction

Suction tubing and containerSuction tubing and container

Safety pinSafety pin

GlovesGloves

StethoscopeStethoscope

Protective pad or towelProtective pad or towel

ProcedureProcedure

Explain the Explain the procedure, benefits, procedure, benefits, risks, complications, risks, complications, and alternatives to and alternatives to the patient or the the patient or the patient's patient's representative.representative.

Examine the patient’s nostril for Examine the patient’s nostril for septal deviation. To determine which septal deviation. To determine which nostril is more patent, ask the patient nostril is more patent, ask the patient to occlude each nostril and breathe to occlude each nostril and breathe through the other.through the other.

Instill 10 mL of viscous lidocaine 2% (for oral Instill 10 mL of viscous lidocaine 2% (for oral use) down the more patent nostril with the head use) down the more patent nostril with the head tilted backwards, and ask the patient to sniff and tilted backwards, and ask the patient to sniff and swallow to anesthetize the nasal and swallow to anesthetize the nasal and oropharyngeal mucosa. In pediatric patients, do oropharyngeal mucosa. In pediatric patients, do not exceed 4 mg/kg of lidocaine. Wait 5-10 not exceed 4 mg/kg of lidocaine. Wait 5-10 minutes to ensure adequate anesthetic effect.minutes to ensure adequate anesthetic effect.

Aspiration of viscous Aspiration of viscous Instillation of viscous Instillation of viscouslidocaine into an oral syringe.lidocaine into an oral syringe. lidocaine 2%.lidocaine 2%.

Estimate the length of insertion by Estimate the length of insertion by measuring the distance from the tip of measuring the distance from the tip of the nose, around the ear, and down to the nose, around the ear, and down to just below the left costal margin. This just below the left costal margin. This point can be marked with a piece of tape point can be marked with a piece of tape on the tube. When using the Salem sump on the tube. When using the Salem sump nasogastric tube (Kendall, Mansfield, nasogastric tube (Kendall, Mansfield, Mass) in adults, the estimated length Mass) in adults, the estimated length usually falls between the second and usually falls between the second and third preprinted black lines on the tube.third preprinted black lines on the tube.

Position the patient sitting upright with the neck partially flexed. Position the patient sitting upright with the neck partially flexed. Ask the patient to hold the cup of water in his or her hand and Ask the patient to hold the cup of water in his or her hand and put the straw in his or her mouth. Lubricate the distal tip of the put the straw in his or her mouth. Lubricate the distal tip of the nasogastric tube.nasogastric tube.

Nasogastric tube lubrication with water-based lubricant.Nasogastric tube lubrication with water-based lubricant.

Gently insert the nasogastric tube along Gently insert the nasogastric tube along the floor of the nose and advance it parallel the floor of the nose and advance it parallel to the nasal floor (ie, directly perpendicular to the nasal floor (ie, directly perpendicular to the patient's head, not angled up into to the patient's head, not angled up into the nose) until it reaches the back of the the nose) until it reaches the back of the nasopharynx, where resistance will be met nasopharynx, where resistance will be met (10-20 cm). At this time, ask the patient to (10-20 cm). At this time, ask the patient to sip on the water through the straw and sip on the water through the straw and start to swallow. Continue to advance the start to swallow. Continue to advance the nasogastric tube until the distance of the nasogastric tube until the distance of the previously estimated length is reached.previously estimated length is reached.

Patient flexing his neck and Patient flexing his neck and drinking water while a nasogastric drinking water while a nasogastric

tube is inserted.tube is inserted.

Stop advancing and completely withdraw the nasogastric Stop advancing and completely withdraw the nasogastric tube if, at any time, the patient experiences respiratory tube if, at any time, the patient experiences respiratory distress, is unable to speak, has significant nasal distress, is unable to speak, has significant nasal hemorrhage, or if the tube meets significant resistance.hemorrhage, or if the tube meets significant resistance.

Verify proper placement of the nasogastric tube by Verify proper placement of the nasogastric tube by auscultating a rush of air over the stomach using the 60 mL auscultating a rush of air over the stomach using the 60 mL Toomey syringe or by aspirating gastric content. The authors Toomey syringe or by aspirating gastric content. The authors recommend always obtaining a chest radiograph in order to recommend always obtaining a chest radiograph in order to verify correct placement, especially if the nasogastric tube is verify correct placement, especially if the nasogastric tube is to be used for medication or food administration.to be used for medication or food administration.

Apply Benzoin or another skin Apply Benzoin or another skin preparation solution to the nose preparation solution to the nose bridge. Tape the nasogastric tube to bridge. Tape the nasogastric tube to the nose to secure it in place. If the nose to secure it in place. If clinically indicated, attach the clinically indicated, attach the nasogastric tube to wall suction after nasogastric tube to wall suction after verification of correct placement.verification of correct placement.


Answer the following true or false questions by just Answer the following true or false questions by just clicking the answer of your choice.clicking the answer of your choice.

Question # 1

Question # 2

Question # 3



When inserting a NGT you have to When inserting a NGT you have to measure first the distance from the tip of measure first the distance from the tip of the nose, around the ear, and down to the nose, around the ear, and down to just below the left costal margin.just below the left costal margin.

a.a. TrueTrueb.b. FalseFalse


Obtaining a chest x-ray is the most Obtaining a chest x-ray is the most reliable means of ensuring proper reliable means of ensuring proper placement of the Nasogastric tube.placement of the Nasogastric tube.




NGT promote distension of the stomach NGT promote distension of the stomach when the person has a bowel when the person has a bowel obstruction. obstruction.



ComplicationsComplications

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

Post TestPost Test1. What is the other name of Enteral Nutrition?___________.1. What is the other name of Enteral Nutrition?___________.2. What is the normal pH of the stomach that will determine 2. What is the normal pH of the stomach that will determine

the correct placement of the tube?____________________.the correct placement of the tube?____________________.3. The commonly use nasogastric tube is called 3. The commonly use nasogastric tube is called

____________.____________.4. By inserting this tube, you are gaining access to the 4. By inserting this tube, you are gaining access to the

stomach and its contents. What do you call that tube?stomach and its contents. What do you call that tube?5. Excessive ____________________ or ___________________ 5. Excessive ____________________ or ___________________

during placement including coughing or gagging may during placement including coughing or gagging may potentiate cervical injury. potentiate cervical injury.

6. Give me 5 Equipments used in NGT insertion6. Give me 5 Equipments used in NGT insertion7. Give me 3 ways on how you could verify the tube 7. Give me 3 ways on how you could verify the tube

placement.placement.8. Give me 2 serious complications of NGT insertion.8. Give me 2 serious complications of NGT insertion.

Click on the numbers to reveal the

answers

1.1.Total enteral Total enteral nutrition (TEN)nutrition (TEN)

Answers to Post Test.Answers to Post Test.

2. pH 5.5 or below2. pH 5.5 or below


3. Levin Tube3. Levin Tube


4. Nasogastric 4. Nasogastric TubeTube



5. Manipulation or 5. Manipulation or movement by the movement by the

patientpatient

6. Equipments during NGT 6. Equipments during NGT insertioninsertion

Nasogastric tubeNasogastric tube Viscous lidocaine 2%Viscous lidocaine 2% Oral analgesic spray (Benzocaine spray or other)Oral analgesic spray (Benzocaine spray or other) Oral syringe, 12 mLOral syringe, 12 mL Glass of water with a strawGlass of water with a straw Water-based lubricantWater-based lubricant Toomey syringe, 60 mLToomey syringe, 60 mL TapeTape Emesis basin or plastic bagEmesis basin or plastic bag Wall suction, set to low intermittent suctionWall suction, set to low intermittent suction Suction tubing and containerSuction tubing and container Safety pinSafety pin GlovesGloves StethoscopeStethoscope Protective pad or towelProtective pad or towel

7. Verifying Tube Placement7. Verifying Tube Placement Chest X-rayChest X-ray Aspirating gastric contents with the irrigation Aspirating gastric contents with the irrigation

syringesyringe While listening over the epigastrum with a While listening over the epigastrum with a

stethoscope quickly instill a 30cc air bolus stethoscope quickly instill a 30cc air bolus with the irrigation syringe. Air entering the with the irrigation syringe. Air entering the stomach will produce a “whooshing” sound.stomach will produce a “whooshing” sound.

Ask the patient to hum or talk. Coughing, Ask the patient to hum or talk. Coughing, cyanosis or choking may indicate that the NGT cyanosis or choking may indicate that the NGT has passed through the larynx.has passed through the larynx.

Place the open end of the NGT in a cup of Place the open end of the NGT in a cup of water. Persistent bubbling may indicate that water. Persistent bubbling may indicate that the NGT has passed through the larynx.the NGT has passed through the larynx.

8. Complications8. Complications

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

I hope you have enjoyed your I hope you have enjoyed your experience and have learned experience and have learned some new information about some new information about Nasogastric Tube Insertion.Nasogastric Tube Insertion.

nasogastric tube insertion

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