Nasogastric Tube (NGT) insertion and removal

Slide 1: Nasogastric tube (NGT) insertion and removal Nursing Procedure

Slide 2: • Usually inserted to decompress the stomach, a nasogastric tube (NG) tube prevent vomiting after major surgery. An NG typically is in place for 48-72 hours after surgery, by which time peristalsis usually resumes.

Slide 3: The NG tube can also be used to assess and treat: Upper GI bleeding Collect gastric contents for analysis Perform gastric lavage Aspirate gastric secretions Administer medications and nutrients

Slide 4: Equipments needed

Slide 5: Equipments needed • Tube (usually #12, #14, #16 or #18 French for a normal adult.

Slide 6: Equipments needed • Towel or linen-saver pad

Slide 7: Equipments needed • Penlight

Slide 8: Equipments needed • 1” or 2” hypoallergenic tape or Opsite

Slide 9: Equipments needed • Liquid skin barrier

Slide 10: Equipments needed • Gloves

Slide 11: Equipments needed • Water soluble lubricant

Slide 12: Equipments needed • Cup or glass of water with straw (if appropriate)

Slide 13: Equipments needed • Stethoscope

Slide 14: Equipments needed • Tongue blade

Slide 15: Equipments needed • Catheter-tip or bulb syringe or irrigation set

Slide 16: Equipments needed • Safety pin

Slide 17: Equipments needed • Ordered suction equipment

Slide 18: Equipments needed (optional) • Metal clamp

Slide 19: Equipments needed (optional) • Ice

Slide 20: Equipments needed (optional) • Alcohol pad

Slide 21: Equipments needed (optional) • Warm water • (in the picture is a hot water bag)

Slide 22: Equipments needed (optional) • Large basin or plastic container

Slide 23: Equipments needed (optional) • Rubber band

Slide 24: Preparation • To ease insertion, increase a stiff tube’s flexibility by coiling it around your finger for a few seconds or by dipping it into warm water. • Stiffen a limp rubber tube by briefly chilling it in ice.

Slide 25: Procedure • Provide privacy, wash your hands, and put on gloves.

Slide 26: Inserting an NG tube • Explain the procedure to the patient. • Tell her that she may experience some discomfort and that swallowing will ease the tube’s advancement.

Slide 28: Inserting an NG tube • Help the patient into high Fowler’s position unless contraindicated.

Slide 29: Inserting an NG tube • Stand at the patient’s right side if you’re right-handed or at her left side if you’ left-handed to ease insertion.

Slide 30: Inserting an NG tube • Drape the towel or linen- saver pad over the patient’s chest.

Slide 31: Inserting an NG tube • To determine how long the NG tube must be to reach the stomach, hold the end of the tube at the tip of the patient’s nose. • Extend the tube to the patient’s earlobe and then down to the xiphoid process.

Slide 33: Inserting an NG tube • Mark this distance on the tubing with tape.

Slide 34: Inserting an NG tube • To determine which nostril will allow easier access, use a penlight and inspect for a deviated septum or other abnormalities.

Slide 36: Inserting an NG tube • Lubricate the first 3” (7.6 cm) of the tube with a water-soluble gel.

Slide 38: Inserting an NG tube • Instruct the patient to hold her head straight and upright.

Slide 39: Inserting an NG tube • Grasp the tube with the end pointing downward, curve it if necessary, and carefully insert it into the more patient nostril.

Slide 41: Inserting an NG tube • Aim the tube downward and toward the ear closest to the chosen nostril. • Advance it slowly to avoid pressure on the turbinates and resultant pain and bleeding.

Slide 42: Inserting an NG tube • When the tube reaches the nasopharynx, you’ll feel resistance.

Slide 44: Inserting an NG tube • Instruct the patient to lower her head slightly to close the trachea and open the esophagus.

Slide 46: Inserting an NG tube • Then rotate the tube 180 degrees toward the opposite nostril to redirect it so that the tube wont enter the patient’s mouth.

Slide 47: Inserting an NG tube • Unless contraindicated, offer the patient a cup of water with a straw. • Direct her to sip and swallow as you slowly advance the tube. • This helps the tube pass to the esophagus. (If you aren’t using water, ask the patient to swallow.)

Slide 49: Ensuring proper tube placement • Use a tongue blade and penlight to examine the patient’s mouth and throat for signs of a coiled section of tubing.

Slide 50: Ensuring proper tube placement • As you carefully advance the tube and the patient swallows, watch for respiratory distress signs, which may mean the tube is in bronchus and must be removed immediately.

Slide 51: Ensuring proper tube placement • Stop advancing the tube when the tape mark reaches the patient’s nostril.

Slide 52: Ensuring proper tube placement • Attach the catheter-tip or bulb syringe to the tube and try to aspirate stomach contents.

Slide 54: Ensuring proper tube placement • If you don’t obtain stomach contents, position the patient on her left side to move the contents into the stomach’s greater curvature, and aspirate again.

Slide 55: Ensuring proper tube placement • If you still can’t aspirate stomach contents, advance the tube 1” to 2” (2.5 - 5 cm). • Then inject 10cc air into the tube.

Slide 56: Ensuring proper tube placement • At the same time, auscultate for air sounds with your stethoscope placed over the epigastric region. • You should hear a whooshing sound if the tube is patent and properly positioned in the stomach.

Slide 58: Ensuring proper tube placement • If these test don’t confirm proper tube placement, you’ll need X-ray verification.

Slide 60: Example of a CXR showing a misplaced NG tube

Slide 61: Ensuring proper tube placement • Secure the NG tube to the patient’s nose with hypoallergenic tape, (or other designated tube holder). • If the patient’s skin is oily, wipe the bridge of her nose with an alcohol pad and allow to dry.

Slide 64: Ensuring proper tube placement • Apply liquid skin barrier to make the tape more adherent to the skin.

Slide 65: Ensuring proper tube placement • You’ll need about 4” (10 cm) of 1”tape. • Split one end of the tape up the center about 1 ½” (3.8 cm). • Make tabs on the split ends (by folding sticky sides together).

Slide 66: Ensuring proper tube placement • Stick the uncut tape end on the patient’s nose so that the split in the tape starts about ½” (1.3 cm) to 1 ½” from the tip of her nose.

Slide 67: Ensuring proper tube placement • Crisscross the tabbed ends around the tube. • Then apply another piece of tape over the bridge of the nose to secure the tube.

Slide 68: Ensuring proper tube placement • Alternatively, stabilize the tube with Opsite or a prepackaged product that secures and cushions it at the nose.

Slide 69: Ensuring proper tube placement • To reduce discomfort from the weight of the tube, tie a slipknot around the tube with a rubber band, and then secure the rubber band to the patient’s gown with a safety pin, or wrap another piece of tape around the end of the tube and leave a tab. • Then fasten the tape tab to the patient’s gown.

Slide 70: Ensuring proper tube placement • Attach the tube to suction equipment, if ordered, and set the designated suction pressure.

Slide 71: Ensuring proper tube placement • Provide frequent nose and mouth care while the tube is in place. • An NG tube may be inserted or removed at home.

Slide 72: *Confirming NG tube placement • When confirming NG tube placement, never place the tube’s end in a container of water. • If the tube is malpositioned in the trachea, the patient may aspirate water.

Slide 73: *Confirming NG tube placement • Besides, water without bubbles doesn’t confirm proper placement. • Instead, the tube may be coiled in the trachea or the esophagus.

Slide 74: Removing an NG tube • Explain the procedure to the patient and that it may cause some discomfort.

Slide 76: Removing an NG tube • Assess bowel function by auscultating for peristalsis or flatus.

Slide 78: Removing an NG tube • Help the patient into semi- Fowler’s position. • Then drape a towel or linen-saver pad across her chest to protect her from spills.

Slide 80: Removing an NG tube • Put on gloves. • Using a catheter-tip syringe, flush the tube with 10ml of normal saline solution to ensure that the tube doesn’t contain stomach contents that could irritate tissues during tube removal.

Slide 82: Removing an NG tube • Untape the tube from the patient’s nose, and then unpin it from her gown.

Slide 83: • Please wear gloves!!!

Slide 84: Removing an NG tube • Clamp the tube by folding it in your hand.

Slide 85: Removing an NG tube • Ask the patient to hold her breath to close the epiglottis. • Then withdraw the tube gently and steadily. (when the distal end of the tube reaches the nasopharynx, you can pull it quickly.)

Slide 86: • Please wear gloves!!!

Slide 87: Removing an NG tube • Assist the patient with thorough mouth care, and clean the tape residue from her nose with adhesive remover.

Slide 88: Removing an NG tube • Monitor the patient for signs of GI dysfunction.

Slide 90: Pointers • If the patient has a nasal condition that prevents nasal insertion, pass the tube orally after removing any dentures, if necessary.

Slide 91: Pointers • First coil the end of the tube around your hand. • This helps curve and direct the tube downward at the phaynx.

Slide 92: Pointers • While advancing the tube. • Observe for signs that it is entered the trachea, such as choking or breathing difficulties in a conscious patient and cyanosis in an unconscious patient or a patient without a cough reflex.

Slide 94: Pointers • If these signs occur, remove the tube immediately. • Allow the patient time to rest; then try to reinsert the tube.

Slide 95: Pointers • After tube placement, vomiting suggest tubal obstruction or incorrect position. • Assess immediately to determine the cause.

Slide 96: Complications of NG intubation • Although nasogastric (NG) intubation is a common procedure, it does carry risk.

Slide 97: Complications of NG intubation (Long-term concerns) • Potential complications of prolonged intubation includes:  Esophagitis  Esophagotracheal fistula  Gastric ulceration  Pulmonary and oral infection  Sinusitis  Skin erosion at the nostril

Slide 98: Complications of NG intubation (Suction reactions) • Additional complications include:  Electrolyte imbalances  Dehydration

Slide 99: Complications of NG intubation (Suction reactions) • Vigorous suction ,ay damage the gastric mucosa and cause significant bleeding, possibly interfering with endoscopic assessment and diagnosis.

Slide 100: Using an NG tube at home • If your patient will have a nasogastric (NG) tube in place at home, find out who will insert the tube. • If he will have a home care nurse, tell him to expect her.

Slide 101: Using an NG tube at home • Make a list; check it twice • If the patient or a family member will perform the procedure, you’ll need to provide additional instruction and supervision.

Slide 102: Using an NG tube at home • Use this checklist to prepare teaching topics: How and where to obtain equipment needed for home intubation. How to insert the tube.

Slide 103: Using an NG tube at home How to verify tube placement by aspirating stomach contents. How to correct tube misplacement. How to prepare formula for tube feeding. How to store formula, if appropriate.

Slide 104: Using an NG tube at home How to administer formula through the tube. How to remove and dispose of an NG tube. How to clean and store a reusable NG tube.

Slide 105: Using an NG tube at home How to use the NG tube for gastric decompression, if appropriate. How to set up and operate suctioning equipment. How to troubleshoot suctioning equipment. How to perform mouth care and other hygenic procedures.

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