Description

Nasogastric (NG) intubation is a procedure in which a thin, plastic tube is inserted into the
nostril, toward the esophagus, and down into the stomach.

Once an NG tube is properly placed and secured, healthcare providers such as the nurses can
deliver food and medicine directly to the stomach or obtain substances from it.

The technique is often used to deliver food and medicine to a patient when they are unable to
eat or swallow.

NG tubes are usually short and are used mostly for suctioning stomach contents and
secretions.

Types of Tubes

Tubes that pass from the nostrils into the duodenum or jejunum are called nasoenteric tubes.
The length of these tubes can either be medium (used for feeding) or long (used for
decompression, aspiration).
Levine tube and salem sump tube are two most commonly used GI tubes for NG intubation.

There are various tubes used in GI intubation but the following two are the most common:

 Levin tube. Is a single-lumen multipurpose plastic tube that is commonly used in NG

intubation.
 Salem sump tube. A double-lumen tube with a “pigtail” used for intermittent or
continuous suction.

Benefits

For patients to gain adequate nutrition and medication especially for those who are unable to
eat and drink. Also, NG intubation is a less invasive alternative to surgery in the event an
intestinal obstruction can be removed easily without surgery.

Indications

By inserting an NG tube, you are gaining an entry or direct connection to the stomach and its
contents. Therapeutic indications for NG intubation include:

 Gastric decompression. The nasogastric tube is connected to suction to facilitate

decompression by removing stomach contents. Gastric decompression is indicated for
bowel obstruction and paralytic ileus and when surgery is performed on the stomach
or intestine.
 Aspiration of gastric fluid content. Either for lavage or obtaining a specimen for
analysis. It will also allow for drainage or lavage in drug overdosage or poisoning.
 Feeding and administration of medication. Introducing a passage into the GI tract
will enable a feeding and administration of various medications. NG tubes can also be
used for enteral feeding initially.
 Prevention of vomiting and aspiration. In trauma settings, NG tubes can be used to
aid in the prevention of vomiting and aspiration, as well as for assessment of GI
bleeding.

Contraindications

Nasogastric intubation is contraindicated in the following:

 Recent nasal surgery and severe midface trauma. These two are the absolute
contraindications for NG intubation due to the possibility of inserting the tube
intracranially. An orogastric tube may be inserted, in this case.
 Other contraindications include: coagulation abnormality, esophageal varices,
recent banding of esophageal varices, and alkaline ingestion.
Risks and Complications

As with most procedures, NG tube insertion is not all beneficial to the patient as certain risks
and complications are involved:

 Aspiration. The main complication of NG tube insertion include aspiration.

 Discomfort. A conscious patient may feel a little discomfort while the NG tube is
passed through the nostril and into the stomach which can induce gagging or
vomiting. A suction should always be present and ready to be used in this case.
 Trauma. The tube can injure the tissue inside the sinuses, throat, esophagus, or
stomach if not properly inserted.
 Wrong placement. Unwanted scenarios such as wrong placement of an NG tube into
the lungs will allow food and medicine pass through it that may be fatal to the patient.
 Other complications include: abdominal cramping or swelling from feedings that
are too large, diarrhea, regurgitation of the food or medicine, a tube obstruction or
blockage, a tube perforation or tear, and tubes coming out of place and causing
additional complications
 An NG tube is meant to be used only for a short period of time. Prolonged use can
lead to conditions such as sinusitis, infections, and ulcerations on the tissue of your
sinuses, throat, esophagus, or stomach.

Nursing Considerations

The following are the nursing considerations you should watch out for:

 Provide oral and skin care. Give mouth rinses and apply lubricant to the patient’s
lips and nostril. Using a water-soluble lubricant, lubricate the catheter until where it
touches the nostrils because the client’s nose may become irritated and dry.
 Verify NG tube placement. Always verify if the NG tube placed is in the stomach by
aspirating a small amount of stomach contents. An X-ray study is the best way to
verify placement.
 Wear gloves. Gloves must always be worn while starting an NG because potential
contact with the patient’s blood or body fluids increases especially with inexperienced
operator.
 Face and eye protection. On the other hand, face and eye protection may also be
considered if the risk for vomiting is high. Trauma protocol calls for all team
members to wear gloves, face and eye protection and gowns.

Inserting a Nasogastric Tube (NGT)

Learn the technique in inserting a nasogastric tube with this step-by-step procedure.

Supplies and Equipment

 Gloves
 Nasogastric tube
 Water-soluble substance (K-Y jelly)
 Protective towel covering for client
  Emesis basin
 Tape for marking placement and securing tube
 Glass of water (if allowed)
 Straw for glass of water
 Stethoscope
 60-mL catheter tip syringe
 Rubber band and safety pin
 Suction equipment or tube feeding equipment

Note: Aside from the primary operator, another person may be needed for insertion to assist
the client with positioning, holding the glass of water (if allowed), and encouragement.

Preparation

Unlike the person that will perform the procedure, patients do not really have to prepare for
an NG intubation or feeding. However, a patient may need to blow their nose and take a few
sips of water (if allowed) before the procedure. Once the tube is inserted into the nostril, the
patient may need to swallow or drink water to help ease the NG tube through the esophagus.

Anesthesia

In some institutions, topical anesthesia for nasogastric (NG) intubation have been
considered. It is used for pain relief and improve the possibility of successful NG intubation.

Another method used prior to the procedure is the viscous lidocaine (the sniff and swallow
method). It was found to significantly reduce the pain and gagging sensation associated with
NG tube insertion.

Alternative techniques include the following:

 Nebulization of lidocaine 1% or 4% through a face mask

 An anesthetic spray of benzocaine or a tetracaine/benzocaine/butyl aminobenzoate
combination

Steps in Inserting a Nasogastric Tube

Listed below are the step-by-step procedure in inserting a nasogastric tube.

1 Review the physician’s order and know the type, size, and purpose of the NG tube. It
is widely acceptable to use a size 16 or 18 French for adults while sizes suitable for children
vary from a very small size 5 French for children to size 12 French for older children.

2 Check the client’s identification band. Just like in administering medications, it is very
important to be sure that the procedure is being carried out on the right client.

3 Gather equipment, set up tube-feeding equipment or suction equipment mentioned

above. This is to make sure that the equipment is functioning properly before using it on the
client.
4 Briefly explain the procedure to the client and assess his capability to participate. It is
not advisable to explain the procedure too far in advance because the client’s anxiety about
the procedure may interfere with its success. It is important that the client relax, swallow, and
cooperate during the procedure.

5 Observe proper hand washing and don non-sterile gloves. Clean, not sterile, technique
is necessary because the gastrointestinal (GI) tract is not sterile.

6 Position client upright or in full Fowler’s position if possible. Place a clean towel over
the client’s chest. Full Fowler’s position assists the client to swallow, for optimal neck-
stomach alignment and promotes peristalsis. A towel is used as a covering to protect bed
linens and the client’s gown.

7 Measure tubing from bridge of nose to earlobe, then to the point halfway between the
end of the sternum and the navel. Mark this spot with a small piece of temporary tape or
note the distance. Each client will have a slightly different terminal insertion point.
Measurements must be made for each individual’s anatomy.

8 Wipe the client’s face and nose with a wet towel. Wipe down the exterior of the nose
with an alcohol swab. The NG tube will stay more secure if taped on a clean, non oily nose. If
the nose has been cleaned with an alcohol swab, the tape will stay more secure and the tube
will not move in the throat—causing gagging or discomfort later.

9 Cover the client’s eyes with a cloth. This protects the client’s eyes from any alcohol
fumes from the alcohol swab.

10 Examine nostrils for deformity or obstruction by closing one nostril and then the
other and asking the client to breathe through the nose for each attempt. If the client has
difficulty breathing out of one nostril, try to insert the NG tube in that one. The client may
breathe more comfortably if the “good” nostril remains patent.The blocked nasal passage
may not be totally occluded and thus you may still be able to pass an NG tube. It may be
necessary to use the more patent nostril for insertion.

11 Lubricate 4 to 8 inches of the tub with a water-soluble lubricant. The NG intubation is

very uncomfortable for many patients, so a squirt of Xylocaine jelly in the nostril, and a spray
of Xylocaine to the back of the throat will help alleviate the discomfort.

12 Flex the client’s head forward, tilt the tip of the nose upward and pass the tube
gently into the nose to as far as the back of the throat. Guide the tube straight
back. Flexing the head aids in the anatomic insertion of the tube.The tube is less likely to
pass into the trachea.
13 Once the tube reaches the nasopharynx, allow the client lower his head slightly. Ask
the assistant to hold the glass of water. Ready the emesis basin and tissues. The positioning
helps the passage of the NG to follow anatomic landmarks. Swallowing water, if allowed,
helps the passage of the NG tube.

14 Instruct the client to swallow as the tube advances. Advance the tube until the correct
marked position on the tube is reached. Encourage the client to breathe through his
mouth. Swallowing of small sips of water may enhance passage of tube into the stomach
rather than the trachea.

15 If changes occur in patient’s respiratory status, if tube coils in mouth, if the patient
begins to cough or turns cyanotic, withdraw the tube immediately. The tube may be in
the trachea.

16 If obstruction is felt, pull out the tube and try the other nostril. The client’s nostril
may deflect the NG into an inappropriate position. Let the client rest a moment and retry on
the other side.

17 Advance the tube as far as the marked insertion point. Place a temporary piece of tape
across the nose and tube. In this way, you can check for placement before securing the tube.
The tube may move out of position if not secured before checking for placement.

18 Check the back of the client’s throat to make sure that the tube is not curled in the
back of the throat. On instance, the NG will curl up in the back of the throat instead of
passing down to the stomach. Visual inspection is needed in this situation. Withdraw the
entire tube and start again if such thing occurred.
19 Check tube placement with these methods. Check the tube for correct placement by at
least two and preferably three of the following methods:

A. Aspirate stomach contents. Stomach aspirate will appear cloudy, green, tan, off-white,
bloody, or brown. It is not always visually possible to distinguish between stomach and
respiratory aspirates. Special note: The small diameters of some NG tubes make aspiration
problematic. The tubes themselves collapse when suction is applied via the syringe. Thus,
contents cannot be aspirated.

B. Check pH of aspirate. Measuring the pH of stomach aspirate is considered more accurate

than visual inspection. Stomach aspirate generally has a pH range of 0 to 4, commonly less
than 4. The aspirate of respiratory contents is generally more alkaline, with a pH of 7 or
more.

C. Inject 30 mL of air into the stomach and listen with the stethoscope for the “whoosh”
of air into the stomach. The small diameter of some NG tubes may make it difficult to hear
air entering the stomach.

D. Confirm by x-ray placement. X-ray visualization is the only method that is considered
positive.

20 Secure the tube with tape or commercially prepared tube holder once stomach
placement has been confirmed. It is very important to ensure that the NG tube is in its
correct place within the stomach because, if by accident the NG is within the trachea, serious
complications in relation to the lungs would appear. Securing the tube in place will prevent
peristaltic movement from advancing the tube or from the tube unintentionally being pulled
out.

Outlook

After the procedure is done, with NG tube intact and secured, the primary purpose of it is
now ready to be applied. Patients equipped with the NG tube must maintain good oral
hygiene and the need to clean their nose regularly. The healthcare team is also entitled to
check for any irregularities such as signs of irritation, infection, or ulceration while the NG
tube is in place.

Aside from administering drugs and other oral agents, an NG tube is widely used to carry
food to the stomach through the nose. It can be used for all feedings or for giving a person
extra calories.

Administering Tube Feeding

Supplies and Equipment

 Gloves Feeding pump (if ordered)

 Clamp (optional)
 Feeding solution
 Large catheter tip syringe (30 mL or larger)
  Feeding bag with tubing
 Water
 Measuring cup
 Other optional equipment (disposable pad, pH indicator strips, water-soluble
lubricant, paper towels)

Steps in Tube Feeding

The following are the step in administering tube feeding via nasogastric tube.

1 Prepare formula. Follow the substeps below:

1.1. Check expiration date. Outdated formula may be contaminated or have reduced
nutritional value.

1.2. Shake can thoroughly. Feeding solution may settle and mixing is necessary just before
administration.

1.3. For powdered formula, mix according to the instructions on the package. Prepare
just enough for the next 24 hours and refrigerate unused formula. Allow formula to
reach room temperature before using. Formula loses its nutritional value and can be
contaminated if kept for more than 24 hours. Cold formulas can cause abdominal discomfort.

2 Explain the procedure to the client. Providing the right information may result to client’s
cooperation and understanding.

3 Always check the position of the client. Make sure that the position of the client with a
tube feeding remain with the head of bed elevated at least 30 to 40 degrees. Never feed
the client with supine position. Semi-Fowler’s or full-Fowler’s position prevents aspiration
pneumonia and possible death due to pulmonary complications.

4 Check placement of feeding tube by:

A. Aspirating stomach contents. This indicates that the tube is in its proper place in the
stomach. The amount of residual reflects gastric emptying time and indicates if feeding
should proceed. This contents are returned to the stomach because they contain
valuable electrolytes and digestive enzymes.

1. Connect syringe to end of feeding tube.

2. Pull back on plunger carefully.
3. Determine amount of residual fluid (clamp tube if it is necessary to remove the
syringe).
4. Return residual to stomach via tube and continue with feeding if amount does not
exceed agency protocol or physician’s orders.

B. Injecting 10 to 20 mL of air into tube (3–5 mL for children). A whooshing or gurgling

sound usually indicates that the tube is in the stomach.This method may not be a reliable
indicator with small-bore feeding tubes.

1. Connect syringe filled with air to tube.

 2. Inject air while listening with stethoscope over left upper quadrant.

C. Measuring the pH of aspirated gastric secretions. Gastric contents are acidic, and a pH
indicator strip should reflect a range of 1 to 4. Pleural fluid and intestinal fluid are slightly
basic in nature.

D. Taking an x-ray or ultrasound. This may be needed to determine tube placement. X-ray
visualization is the only method that is considered positive.

Intermittent or Bolus Feeding

5 If using a feeding bag:

5.1 Suspend the feeding bag about 12 to 18 inches inches above the stomach. Clamp the
tubing. Fill the bag with prescribed formula and prime the tubing by opening the
clamp, allowing the feeding to flow through the tubing. Clamp the tube. Formula clears
air from the tubing and prevents it from entering the stomach.

5.2 Connect tip of the setup to the gastric tube and open the clamp. Adjust flow
according to the physician’s order. Feeding very quickly may cause nausea and abdominal
cramping.

5.3 As feeding is completed, add 30 to 60 mL of water to the feeding bag. Clamp the
tube and disconnect the feeding setup. This allows the tube to be cleared, keeping it patent.
Clamping after feeding is completed prevents air from entering the stomach.

6 If using a syringe:

6.1 Clamp the gastric tube. Connect the tip of the large syringe, with the plunger or
bulb removed, into the gastric tube. Gently pour feeding into the syringe. Raise the
syringe 12 to 18 inches above the stomach. Open the clamp. Gravity promotes movement
of feeding into the stomach.

6.2 Allow feeding solution to flow slowly into the stomach. Raise and lower the syringe
to control the rate of flow. Add additional formula to the syringe as it empties until
feeding is complete. Controlling administration and flow rate of feeding solution prevents air
from entering the stomach and nausea and abdominal cramping from developing.

Continuous Feeding

7 If using a feeding pump:

7.1 Clamp the feeding setup and suspend on pole. Add feeding solution to the bag. Open
the clamp and prime the tubing. Formula clears air from the tubing and prevents it from
entering the stomach. Feeding pump.
7.2 Thread the tubing through or load tubing into the pump, according to the
manufacturer’s specifications.

7.3 Connect the tip of the setup to the gastric tube. Set the prescribed rate and volume
according to the manufacturer’s directions. Open the clamp and turn on the
pump. Pump regulates the rate of administration and volume of formula.

7.4. Stop the feeding every 4 to 8 hours and assess the residual. Flush the tube every 6 to
8 hours. The amount of residual reflects gastric emptying time and indicates whether the
feeding should continue. Flushing clears the tube and keeps it patent.

8 Stop feeding when completed. Instill prescribed amount of water. Keep the client’s
head elevated for 20 to 30 minutes. Elevated position prevents the client from aspiration of
feeding solution into the lungs.

9 Regularly assess the skin around the injection site of surgically placed tubes. Cleanse
skin with mild soap and water and dry thoroughly. Check site for redness, swelling,
pain, or additional signs of inflammation. Careful assessment and care can prevent spread
infection and skin breakdown.

10 Always observe proper hygiene by providing mouth care such as brushing teeth,
offering mouthwash, and keeping the lips moist. These activities promote oral hygiene and
improve comfort.

Monitoring a Nasogastric Tube

Objectives

 To check the intactness of the tube into the stomach.

 To monitor the flow rate of feeding.

Charting

 Intactness of the tube

 Check amount, color, consistency and odor of drainage from Nasogastric tube.
 Patient’s activities and reaction.

Steps in Monitoring a Nasogastric Tube

The following are the step-by-step procedures in monitoring a nasogastric tube:

1 Confirm physician’s order for NG tube, type of suction, and direction for
irrigation. Ensures correct implementation of physician’s order.

2 Observe drainage from NG tube. Check amount, color, consistency, and odor.
Hematest drainage to confirm presence of blood in drainage. Normal color of gastric
drainage is light yellow to green in color due to the presence of bile. Bloody drainage may be
expected after gastric surgery but must be monitored closely. Presence of coffee-ground type
drainage may be indicate bleeding.

3 Inspect suction apparatus. Check that setting is correct for type of suction (continuous
or intermittent), range of suction (low,medium,high) and that movement of drainage
through tubing is present. Ensures correct implementation of physician’ order. Ensures that
suction is present and correctly adjusted. Loose connections or a kind or blockage in tube
may interfere with suction.

4 Assess placement of NG tube. NG tube may be displaced into trachea through movement
or manipulation.

5 Assess comfort of client. Check for presence of nausea and vomiting, feeling of
fullness, or pain. May indicate incorrect operation of NG suction or blockage in tube.

6 Assess client’s abdomen for distension and auscultate for presence of

bowel sounds. Abdominal distention may be related to the accumulation of gas or internal
bleeding. Presence of bowel sounds indicates the return of peristalsis.

7 Assess mobility of client and respiratory status.

Turning from side to side in bed and ambulation when permitted encourage the return of
peristalsis and facilitate drainage. Presence of NG tube may discourage client from coughing
and deep breathing necessary for adequate respiratory exchange.

8 Observe condition of client’s nostrils and oral cavity. Nostrils need cleansing and
lubrication with water-soluble lubricant and tape must be changed when necessary to
minimize irritation from NG tube. Frequent mouth care (at 2-hr intervals) improves comfort
and maintains moisture in oral mucosa.

9 Monitor overall safety of client with NG tube.

NG tube that is secured to client’s nose with tape and pinned to gown allows easier
movement. Call bell within reach allows client ready access to nursing assistance. Any kinks
or obstruction interferes with patency of NG tube. A semi-Fowler’s position facilitates
drainage and minimizes any risk or aspiration.

10 Monitor NG tube and suction apparatus at least every 2 hours. Irrigate at interval
ordered by physician. Promotes safe operation of system. Any change in client’s condition
or type of drainage necessitates more frequent observation and notification of physician.

11 Record and measure NG irrigations and drainage on intake/output chart according

to schedule and agency protocol. Documents description of drainage and client’s
response on chart. Irrigations are recorded as intake. Drainage from NG tube is measured as
output every 8 hour. If drainage is copious, more frequent emptying of collection container
will be necessary. Documentation provides accurate record of client’s response to NG
drainage.

12 Replenish supplies and maintain equipment according to agency policy and

manufacturer’s recommendations. Ensures availability of necessary supplies. Provides for
safe operation of equipment and efficient drainage of client’s gastric contents.
Irrigating a Nasogastric Tube

A nasogastric tube is irrigated regularly to determine and ensure the tube’s patency. It will
help release any formula stuck to the inside of the tube.

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 suction-drainage 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.

Supplies and Equipment

 Nasogastric tube connected to continuous or intermittent suction.

 Irrigation or Toomey syringe and container for irrigating solution.
 Normal saline for irrigation.
 Disposable pad or bath towel
 Disposable gloves (optional)
 Stethoscope
 Clamp

Steps in Irrigating Nasogastric Tubes

The following is the step-by-step procedure in irrigating nasogastric tubes:

1 Check physician’s order for irrigation. Explain procedure to client. 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. Provides for organized approached to task. Agency policy dictates safe
interval for reuse of equipment.

3 Wash your hands. Handwashing deters the spread of microorganisms.

4 Assist client to semi-Fowler’s position unless this is contraindicated. Minimizes risk of

aspiration.
5 Check placement of NG tube using the following techniques:

A. Attach Asepto or Toomey syringe to the end of tube and aspirate gastric
contents. 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. A whooshing sound can be heard
when the air enters the stomach through the tube.

C. Ask client to speak. 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 disposable pad or towel. 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. 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. 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. 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. Injection of air may reposition the end of tube.

11 Reconnect NG tube to suction. Observe movement of solution or drainage. Determine

patency of NG tube and correct operation of suction apparatus.

12 Measure and record amount and description of irrigant and return solution. Irrigant
placed in NG tube is considered intake: solution returned is recorded as output.

13 Rinse equipment if it will be reused. Promotes cleanliness and prepares equipment for
next irrigation.

14 Wash your hands. Handwashing deters the spread of microorganisms.

15 Record irrigation procedure, description of drainage and client’s response. Facilitates

documentation of procedure and provides for comprehensive care.

Removing a Nasogastric Tube

Objectives
  To check if the patient can tolerate oral feeding.

Contraindications

 Continuing need for feeding/suction.

Nursing Alert: Removal is easier with the patient in semi-Fowler’s position.

Supplies and Equipment

 Tissues
 Plastic disposable bag
 Bath towel or disposable pad
 Clean disposable glove

Steps in Removing Nasogastric Tube

The following is the step-by-step procedure in removing nasogastric tubes:

1 Check physician’s order for removal of nasogastric tube. Ensures correct

implementation of physician’s order.

2 Explain procedure to client. Explanation facilitates client cooperation and understanding.

3 Gather equipment. Makes every step within reach and provides for organized approach to
task.

4 Wash your hands. Don clean disposable glove on hand that will remove
tube. 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 client’s gown
and carefully remove adhesive tape from bridge of nose. Allows for unrestricted removal
of nasogastric tube.

6 Place towel or disposable pad across client’s chest. Hand tissues to client. 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.

Prevents accidental aspiration of any gastric secretions in tube.

8 Clamp tube with fingers. Quickly and carefully remove tube while client holds his
breath. 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. Prevents
contamination with any microorganisms.

10 Offer mouth care to client and make client feel comfortable. Provides comfort.
11 Measure nasogastric drainage. Remove all equipment and dispose according to
agency policy. Wash your hands. Measuring nasogastric drainage provides for accurate
recording of output. Proper disposal deters spread of microorganisms.

12 Record removal of nasogastric tube, client’s response, and measurement of

drainage. Facilitates documentation and provides for comprehensive care.

Charting

 Record date of removal of nasogastric tube.

 Record client’s response.
 Record measurement of drainage.

After Care

 Discard the disposable equipment used.

 Wash your hands.
 Position the patient in a comfortable or in his desired position

Introduction

A nasogastric (NG) tube is a long polyurethane or silicone tube that is passed through the
nasal passages via the oesophagus into the stomach. They are commonly inserted in surgical
practice for various reasons.

According to the National Patient Safety Agency (2005a), 11 deaths and one case of serious
harm occurred over a two-year period because NG feeding tubes had been misplaced.

Nasogastric tubes are inserted by nurses, junior doctors and sometimes by anaesthetists in
theatre. It is vital that staff inserting them know the correct insertion technique as well as the
procedure for verifying their correct positioning. This article reviews the indications for NG
tubes and the benefits and risks associated with their use, and explains the correct method of
insertion, as well as how to verify their correct intragastric positioning.
Indications

There are only two main indications for NG tube insertion – to empty the upper
gastrointestinal tract or for feeding. Insertion may be for prophylactic or therapeutic reasons.

Care should be taken in cases where there may be:

 Ear, nose and throat abnormalities or infections;

 Possible strictures of the oesophagus;
 Oesophageal varices;
 Anatomical abnormalities (oesophageal diverticulae);
 Risk of aspiration.

Gaining consent

Practitioners should give patients a reassuring, detailed explanation of the insertion

procedure, together with the reasons why the tube is necessary. Verbal consent should then be
obtained.

Sizes

Nasogastric tubes come in various sizes (8, 10, 12, 14, 16 and 18 Fr). Stiff tubes are easier to
insert, and putting them in a refrigerator or filling them with saline helps to stiffen them.
Some fine-bore tubes come with a guide wire to aid placement. The tube has markings and a
radio-opaque marker at the tip to check its position on X-ray.

Preparation

After washing hands, prepare a trolley including gloves, local anaesthetic jelly or spray, a
60ml syringe, pH strip, kidney tray, sticky tape and a bag to collect secretions. Placing a glass
of drinking water nearby is useful.

Insertion technique

Tubes are usually inserted by nurses or junior doctors by the bedside or by anaesthetists in
theatre before or during surgery.

External measurement from the tip of the nose to a point halfway between the xiphoid and the
umbilicus distance gives a rough idea of the required length.

The patient should sit up, without any head tilt (chin up). An appropriately sized tube is
chosen and the tip is lubricated by smearing aqua gel or local anaesthetic gel. Anaesthetic gel
is a drug so if it is used it must be prescribed, and precautions taken such as checking for
allergies.

The wider nostril is chosen and the tube slid down along the floor of the nasal cavity. Patients
often gag when the tube reaches the pharynx. Asking them to swallow their saliva or a small
amount of water may help to direct the tube into the oesophagus. Once in the oesophagus, it
may be easy to push it down into the stomach.
The correct intragastric position is then verified (see below). The tube is fixed to the nose and
forehead using adhesive tapes. The stomach is decompressed by attaching a 60ml syringe and
aspirating its contents. Blocked tubes can be flushed open with saline or air.

Verifying correct intragastric positioning

The intragastric position of the tube must be confirmed after its initial insertion, and this must
be documented in the patient’s notes. There are two ways of confirming the tube’s position
currently recommended. These are by pH test (Stock et al, 2008; NPSA, 2005a; 2005b) and
X-ray. Other methods can be inaccurate and should not be used.

pH test

The NG tube is aspirated and the contents are checked using pH paper, not litmus paper
(Earley, 2005). The NPSA (2005b) recommended that it is safe to feed patients (infants,
children and adults) if the pH is 5.5 or below. This advice does not apply to neonates
(preterm to 28 days). See the NPSA’s (2005b) advice and the update (2007) for more
information.

Note that taking proton pump inhibitors or H2 receptor antagonists may alter the
pH. Similarly, intake of milk can neutralise the acid.

Chest X-ray

When in doubt, it is best practice to use X-ray to check the tube’s location (Stock et al, 2008).
Patients who have swallowing problems, confused patients and those in ICU should all be
given an X-ray to verify the tube’s intragastric position. This involves taking a chest X-ray
including the upper half of the abdomen. The tip of the tube can be seen as a white radio-
opaque line and should be below the diaphragm on the left side.

Syringe test

This test is mentioned here for historic interest only. Also known as the whoosh test, it has
been shown to be an unreliable method of checking tube placement, and the NPSA (2007;
2005a; 2005b) has said that it must no longer be used.

Confirming position

Correct intragastric positioning should be confirmed:

 Immediately after initial placement;

 Before each feed;
 Following vomiting/coughing and after observing decreased oxygen saturation;
 If the tube is accidentally dislodged or the patient complains of discomfort.
 Never insert the guide wire while the nasogastric tube is in the patient.
Advantages

There are several advantages associated with the use of NG tubes. They will decompress the
stomach by releasing air and liquid contents. This is important for patients with ileus,
intestinal and gastric outlet obstruction. These conditions can cause vomiting, and patients are
at risk of aspirating their stomach contents, which can lead to potentially lethal pneumonitis.

Nasogastric tubes may also be useful for feeding patients who have dysphagia, for example
after experiencing a stroke, and also for those being who have undergone a tracheostomy.

Nasojejunal tubes are longer versions of NG tubes. They are inserted under endoscopic
guidance to lie further in the jejunum and may be useful in feeding patients with pancreatitis.

 Part 2 of this unit looks at complications and guidance on using nasogastric tubes:
Nasgastric tubes 2: risk and guidance on avoiding and dealing with complications

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References:

Dougherty, L., Lister, S. (2008) The Royal Marsden Hospital Manual of Clinical Nursing
Procedures. Chichester: Wiley Blackwell.

Earley, T. (2005) Using pH testing to confirm nasogastric tube position. Nursing Times; 101:
38, 24-6.

National Patient Safety Agency (2007) Advice to the NHS on Reducing Harm Caused by
the Misplacement of Nasogastric Feeding Tubes. Update February 2007. Nasogastric Tube
Incidents: Summary Update. London: NPSA.

National Patient Safety Agency (2005a) Patient Safety Alert 05. Reducing the Harm Caused
by Misplaced Nasogastric Feeding Tubes. London: NPSA.

National Patient Safety Agency (2005b) How to Confirm the Correct Position of
Nasogastric Feeding Tubes in Infants, Children and Adults. London: NPSA.

Stock, A. et al (2008) Confirming nasogastric tube position in the emergency department: pH

testing is reliable. Pediatric Emergency Care; 24: 12, 805-9.

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Risks and possible complications

While properly inserted nasogastric (NG) tubes are useful, if precautions are ignored, they
can lead to several complications. These include:
  The tube may enter the lungs Because of the proximity of the larynx to the oesophagus, the
nasogastric tube may enter the larynx and trachea (Lo et al, 2008). This may cause a
pneumothorax (Zausig et al, 2008).
 When the tube is in the airway, it will cause severe irritation and cough. Asking patients to
hold some water in their mouth and swallowing it while the tube is in the throat may help to
pass the tube into the oesophagus.
 The tube may coil up in the patient’s throat This is particularly likely if if the patient retches.
Refrigerating the tube may help to avoid coiling and keeps it stiff. Alternatively, using a guide
wire can help with both these issues.
 Sinusitis The presence of an NG tube in the nose for an extended period may lead to
damage to the ciliary epithelium and cause infection, which may lead to sinusitis.
 The tube can enter the brain There are case reports of NG tubes perforating the base of the
skull and reaching the brain (Geissler, 2007). A well-lubricated tube may help to decrease
friction during insertion. If the nostrils are of unequal size the wider one should be used. If
resistance is felt, the tube should not be forced.
 Perforation of the oesophagus This is rare (Hutchinson et al, 2008) but may occur in pre-
existing oesophageal disease, for example in the presence of an unrecognised diverticulum
of the oesophagus.
 Retropharyngeal abscess This may occur from perforation of a piriform sinus (Makay et al,
2008; Obon Azuara et al, 2007) and will cause swallowing problems.
 Reflux of stomach contents into the oesophagus and risk of aspirationThe intraluminal
presence of an NG tube may interfere with the lower oesophageal sphincter and cause
reflux of stomach contents, leading to aspiration pneumonitis. The risk is increased when
patients are fed when lying down flat.
 Death from feeding into the lung Feeding through a tube incorrectly placed in the bronchial
tree may cause severe sepsis, which can be fatal.
 ParotitisThis can be prevented by good oral hygiene. Oral bacteria enter the parotid duct,
causing infection of the gland.

Case studies

The case studies illustrated below show incorrect and correct positioning for NG tubes.

Tube in the lung

An 84-year-old woman was admitted to hospital after a stroke leading to dysphagia and
confusion. An NG tube was inserted for feeding. Attempted aspiration did not yield enough
fluid for the verification pH test. A chest X-ray was requested. Fig 1 shows the tube in the
lung. It was removed and reinserted. Fig 2 shows the tube in the correct position.
Tube in the bronchus

This patient was admitted for an orthopaedic procedure and became unwell. A NG feeding
tube had been incorrectly inserted into the bronchus leading to a bronchopleural fistula. When
a chest drain was inserted into the pleural cavity for drainage, nasogastric feed was seen
coming through the chest drain(Fig 3).

Avoiding complications

Many hospitals have developed checklists to avoid complications related to NG tubes. Any
complications that do occurshould be reported on a critical incident form.

Tube position should be checked after coughing or vomiting, as they can migrate.

Auscultation of the epigastric region after insufflation of air through the tube (the ‘whoosh’
test) is unreliable so a pH strip should be used to confirm the correct intragastric position
(Stock et al, 2008). Blue litmus paper cannot distinguish between bronchial and gastric
secretions so should not be used to verify the tube’s correct position.

Confused and unconscious patients may not show respiratory distress even if the tube is in
the respiratory tract.

It may not be easy to differentiate between bronchial secretions and stomach contents without
checking the pH. To avoid false negative results, pH strips should be kept clean during
storage and the syringe with gastric aspirate should not be put back into the syringe cover
(National Patient Safety Agency, 2007a).

For guidance on confirming the correct position of NG feeding tubes in infants, children and
adults, practitioners should consult NPSA (2005) guidance (see Fig 4 for adults).

When NG tubes are used for feeding, care should be taken when administering medications.
Nasogastric medications can be administered intravenously in error (Stock et al, 2008). The
NPSA (2007b) recommended using specifically designed NG syringes, which are
incompatible with IV equipment.
Conclusion

The correct intragastric position of an NG tube should be verified by checking the aspirate for
acidic pH of 5.5 or below (NPSA, 2005), and by an X-ray if necessary. Any complication
related to these tubes should be reported. The whoosh test and litmus papers should not be
used to verify position.

References:

Geissler, K. (2007) Unusual placement of a nasogastric tube. Radiologic Technology; 78: 3,

253.

Hutchinson, R. et al (2008) A case of intramural oesophageal dissection secondary to

nasogastric tube insertion. Annals of the Royal College of Surgeons of England; 90: 7, W4–
W7.

Lo, J.O. et al (2008) Diagnosis and management of a misplaced nasogastric tube into the
pulmonary pleura. Archives of Otolaryngology, Head and Neck Surgery; 134: 5, 547–550.

Makay, O. et al (2008) Pyriform sinus perforation secondary to nasogastric tube insertion.

ANZ Journal of Surgery; 78: 7, 624.

National Patient Safety Agency (2007a) Advice to the NHS on Reducing Harm Caused by
the MisplacementofNasogastric Feeding Tubes. Update February 2007. Nasogastric Tube
Incidents. Summary Update. London: NPSA.

National Patient Safety Agency (2007b) Promoting Safer Measurement and Administration
of LiquidMedicinesvia Oral and Other Enteral Routes. London: NPSA.

National Patient Safety Agency (2005) How to Confirm the Correct Position of Nasogastric
Feeding TubesinInfants, Children and Adults. London: NPSA.

Obon Azuara, B. et al (2007) Adverse events by nasogastric tube placement. Anales de

Medicina Interna; 24: 9, 461–462.

Stock, A. et al (2008) Confirming nasogastric tube position in the emergency department: pH

testing is reliable. Pediatric Emergency Care; 24: 12, 805–809.

Zausig, Y.A. et al (2008) Occurrence of a pneumothorax secondary to malpositioned

nasogastric tube: a case report. Minerva Anestesiologica; 74: 12, 735–738.
64. The nurse is preparing to initiate bolus enteral feedings via nasogastric (NG) tube to a client.
Which of the following actions represents safe practice by the nurse?

a) checks the volume of the residual after administering the bolus feeding
b) aspirates gastric contents prior to initiating the feeding and assures that pH is >9
c) elevates the head of the bed to 25 degrees and maintains for 30 minutes after instillation of
feeding
d) measures the length of the tube from where it protrudes from the nose to the end and compares
to previously documented measurements

64) D
- After initial radiographic confirmation of NG tube placement, methods used to verify nasogastric
tube placement include measuring the length of the tube from the point it protrudes from the nose
to the end; injecting 10 to 30 mL of air into the tube and auscultating over the left upper quadrant of
the abdomen; and aspirating the secretions and checking to see if the pH is between 1 and 5.
Fowler's position is recommended for bolus feedings, if permitted, and should be maintained for 1
hour after instillation. Residual should be assessed before administration of the next feeding.

65. A nurse has inserted a nasogastric (NG) tube to the level of the oropharynx and has repositioned
the client's head in a flexed-forward position. The client has been asked to begin swallowing, and as
the nurse starts to slowly advance the NGT with each swallow, the client begins ti gag. Which
nursing action would least likely result in proper tube insertion and promote client relaxation?

a) pulling the tube back slightly

b) instructing the client to breathe slowly
c) continuing to advance the tube to the desired distance
d) checking the back of the pharynx using a tongue blade and flashlight
65) C
- As the NG tube is passed through the oropharynx, the gag reflex is stimulated, which may cause
gagging. Instead of passing through to the esophagus, the NG tube may coil around itself in the
oropharynx, or it may enter the larynx and obstruct the airway. Because the tube may enter the
larynx, advancing the tube may position it in the trachea. Slow breathing helps the client relax to
reduce the gag response. The tube may be advanced after the client relaxes.