Nasogastric Tube Insertion

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  • According to AmericanGastroenterologic Association
  • Inserting an NG tube requires close observation of the patient and verification of proper placement. Removing the tube requires careful handling to prevent injury or aspiration.The tube must be inserted with extra care in a pregnant patient and in one with an increased risk of complications.Most NG tubes have a radiopaque marker or strip at the distal end so that the tube position can be verified by X –ray. If the position cant be confirmed, the physician may order fluoroscopy to verify placement.
  • The most common NG tubes are the Levin tube, which has one lumen and the Salen sump tube, which has two lumens, one for suction and drainage and one for ventilation. Air flows through the vent lumen continuously. This protects the delicate gastric mucosa by preventing a vacuum from forming should the tube adhere to the stomach lining. The Moss tube, which has a triple lumen, is usually inserted during surgery.
  • The most common NG tubes are the Levin tube, which has one lumen and the Salen sump tube, which has two lumens, one for suction and drainage and one for ventilation. Air flows through the vent lumen continuously. This protects the delicate gastric mucosa by preventing a vacuum from forming should the tube adhere to the stomach lining. The Moss tube, which has a triple lumen, is usually inserted during surgery.
  • The Moss tube, which has a triple lumen, is usually inserted during surgery.
  • According to the fundamentals of science
  • Nasogastric Tube Insertion

    1. 1. Nasogastric tube insertion & removal<br />1<br />
    2. 2. Objectives<br />Discuss nasogastric tube insertion and removal procedure.<br />Describe the types of NG tubes used in the procedure.<br />Demonstrate the correct procedure in performing nasogastric tube insertion and removal procedure.<br />Perform the procedures through return - demonstration correctly.<br />2<br />
    3. 3. 3<br />
    4. 4. According to American Gastroenterologic Association<br /><ul><li>NG tube has other diagnostic and therapeutic applications, especially in
    5. 5. assessing and treating upper GI bleeding,
    6. 6. collecting gastric contents for analysis,
    7. 7. performing gastric lavage,
    8. 8. aspirating gastric secretions, &
    9. 9. administering medications & nutrients.</li></ul>4<br />
    10. 10. 5<br />
    11. 11. Types of NG Tubes<br />6<br />
    12. 12. 7<br />
    13. 13. 8<br />
    14. 14. Salen sump tube <br />Main suction port<br />Air vent<br />9<br />
    15. 15. 10<br />
    16. 16. equipment<br />Insertion of NG tube<br />11<br />
    17. 17. Equipment<br /><ul><li>Tube (usually #12, #14, #16 or #18 French for a normal adult)
    18. 18. Towel or linen – saver pad
    19. 19. Facial tissues
    20. 20. Emesis basin
    21. 21. Penlight
    22. 22. 1 “ or 2” hypoallergenic tape
    23. 23. Gloves
    24. 24. Water – soluble lubricant
    25. 25. Cup or glass of water with straw (if appropriate)</li></ul>12<br />
    26. 26. Equipment<br /><ul><li>pH test strip
    27. 27. Tongue blade
    28. 28. Catheter – tip or bulb syringe or irrigation set
    29. 29. Safety pin
    30. 30. Ordered suction equipment
    31. 31. Optional: metal clamp, alcohol pad, warm water, large basin or plastic container, rubber band</li></ul>13<br />
    32. 32. Preparation of equipment<br />14<br />
    33. 33. Preparation of equipment<br /><ul><li>Inspect the NG tube for defects, such as rough edges or partially closed lumens.
    34. 34. Then check the tube’s patency by flushing it water.
    35. 35. To ease insertion, increase a stiff tube’s flexibility by coiling it around your gloved fingers for a few seconds or by dipping it into warm water.</li></ul>15<br />
    36. 36. Implementation<br />16<br />
    37. 37. Whether you’re inserting or removing an NG tube be sure to …<br /><ul><li>Provide privacy.
    38. 38. Wash hands.
    39. 39. Put on gloves before inserting the tube.
    40. 40. Check the physician’s order to determine the type of tube that should be inserted.</li></ul>17<br />
    41. 41. Inserting an ng tube<br />18<br />
    42. 42. Inserting an NG tube<br />Confirm the patient’s identity using two patient identifiers according to facility policy.<br />Explain the procedure to the patient to ease anxiety and promote cooperation. <br /><ul><li>Inform her that she may experience some nasal discomfort, that she may gag, and that her eyes may water.
    43. 43. Emphasize that swallowing will ease the tube’s advancement. </li></ul>19<br />
    44. 44. Inserting an NG tube<br />Agree on a signal that the patient can use if she wants you to stop briefly during the procedure.<br />Gather and prepare all necessary equipment.<br />Help the patient into high – Fowler’s position unless contraindicated.<br />Stand at the patient’s right side if you’re right – handed or at her left side if you’re left – handed to ease insertion.<br />20<br />
    45. 45. Inserting an NG tube<br />Drape the towel or linen – saver pad over the patient’s chest to protect her gown and bed linens from spills.<br />Have the patient gently blow her nose to clear her nostrils. <br />Place the facial tissues and emesis basin well within the patient’s reach.<br />Help the patient face forward with her neck in a neutral position.<br />21<br />
    46. 46. Inserting an NG tube<br />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.<br />22<br />
    47. 47. 23<br />
    48. 48. Inserting an NG tube<br />Mark this distance on the tubing with tape, or note the marking already on the tube. (Average measurements for an adult range from 22” to 26” [56 to 66 cm].) It may be necessary to add 2” (5.1 cm) to this measurement in tall individuals to ensure entry into the stomach.<br />To determine which nostril will allow easier access, use a penlight and inspect for a deviated septum or other abnormalities. Ask the patient if she ever had nasal surgery or a nasal injury.<br />24<br />
    49. 49. Inserting an NG tube<br /><ul><li>Assess airflow in both nostrils by occluding one nostril at a time while the patient breathes through her nose. Choose the nostril with the better airflow.</li></ul> Lubricate the first 3” (7.6 cm) of the tube with a water – soluble gel to minimize injury to the nasal passages. Using a water – soluble lubricant prevents lipoid pneumonia, which may result from aspiration of an oil – based lubricant or from accidental slippage of the tube into the trachea.<br />25<br />
    50. 50. 26<br />
    51. 51. Inserting an NG tube<br /> Instruct the patient to hold her head straight and upright.<br />Grasp the tube with the end pointing downward, curve it if necessary, and carefully insert it into the more patent nostril.<br />27<br />
    52. 52. Inserting an NG tube<br />Aim the tube downward and toward the ear closer to the chosen nostril. Advance it slowly to avoid pressure on the turbinates and resultant pain and bleeding.<br />When the tube reaches the nasopharynx, you’ll feel resistance. Instruct the patient to lower her head slightly to close the trachea and open esophagus. Then rotate the tube 180 degrees toward the opposite nostril to redirect it so that the tube won’t enter the patient’s mouth.<br />28<br />
    53. 53. Inserting an NG tube<br />Unless contraindicated, offer the patient a cup or glass 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.)<br />29<br />
    54. 54. Ensuring proper tube placement<br />30<br />
    55. 55. Ensuring proper tube placement<br />Use a tongue blade and penlight to examine the patient’s mouth and throat for signs of a coiled section of tubing (especially in an unconscious patient). Coiling indicates an obstruction.<br />Keep an emesis basin and facial tissues readily available for the patient.<br />As you carefully advance the tube and the patient swallows, watch for respiratory distress signs, which may mean the tube is in the bronchus and must be removed immediately.<br />31<br />
    56. 56. Ensuring proper tube placement<br />Stop advancing the tube when the tape mark or the tube marking reaches the patient’s nostril.<br />Attach a catheter – tip or bulb syringe to the tube and try to aspirate stomach contents .<br /><ul><li>If you don’t obtain stomach contents, position the patient on her left side to move the contents intro the stomach’s greater curvature, and aspirate again.</li></ul>32<br />
    57. 57. 33<br />
    58. 58. Ensuring proper tube placement<br /><ul><li>When confirming tube placement, never place the tube’s end in a container of water. If the tube is positioned incorrectly in the trachea, the patient may aspirate water.
    59. 59. Gently aspirate stomach contents.
    60. 60. Examine the aspirate and place a small amount on the pH strip test strip.
    61. 61. Probability of gastric placement is increased if the aspirate has a typical gastric fluid appearance (grassy – green, clear and colorless with mucus shreds, or brown) and the pH is less than or equal to 5.0.</li></ul>34<br />
    62. 62. Ensuring proper tube placement<br />Ideally, proper tube placement should be confirmed by X – ray.<br />35<br />
    63. 63. 36<br />
    64. 64. On Xray… <br /><ul><li>Remember, you are not a radiologist
    65. 65. Check for tip below diaphragm
    66. 66. Does tube cross midline?
    67. 67. When does it deviate from the midline?</li></ul>37<br />
    68. 68. Ensuring proper tube placement<br />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 the nose with an alcohol pad and allow it to dry. <br />38<br />
    69. 69. Ensuring proper tube placement<br /><ul><li>You’ll need about 4” (10 cm) of 1” tape. Split one end of the tape up the center about 1 1/2 “ (4 cm).
    70. 70. Make tabs on the split ends (by folding sticky sides together).
    71. 71. Stick the uncut tape end on the patient’s nose so that the split tape in the tape starts about ½ “ (1.5 cm) to 1 ½” from the tip of her nose.
    72. 72. Crisscross the tabbed ends around the tube. Then apply another piece of tape over the bridge of the nose to secure the tube.</li></ul>39<br />
    73. 73. 40<br />
    74. 74. Ensuring proper tube placement<br />Alternatively, stabilize the tube with a prepackaged product that secures and cushions it at the nose. <br />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. <br />41<br />
    75. 75. Attach the tube to suction equipment, if ordered, and set the designated suction pressure. <br />Provide frequent nose and mouth care while the tube is in place.<br />42<br />
    76. 76. Removing an ng tube<br />43<br />
    77. 77. Equipment<br />Removal of NG tube<br />44<br />
    78. 78. Equipment<br /><ul><li>Gloves
    79. 79. Catheter – tip syringe
    80. 80. Normal saline solution
    81. 81. Towel or linen – saver pad
    82. 82. Adhesive remover
    83. 83. Facial tissues
    84. 84. Optional: clamp</li></ul>45<br />
    85. 85. Removing an NG tube<br />Confirm the patient’s identity using two patient identifiers according to facility policy.<br />Explain the procedure to the patient, informing her that it may cause some nasal discomfort and sneezing or gagging.<br />Assess bowel function by auscultating for peristalsis or flatus.<br />Help the patient into semi – Fowler’s position. Then drape a towel or linen – saver pad across her across to protect her gown and bed linens from spills. <br />46<br />
    86. 86. Removing an NG tube<br />Wash your hands, put on gloves.<br />Using a catheter – tip syringe, flush the tube with 10 ml of normal saline solution to ensure that the tube doesn’t contain stomach contents that could irritate tissues during tube removal.<br />Untape the tube from the patient’s nose, and then unpin it from her gown. <br />Clamp the tube by folding it in your hand.<br />47<br />
    87. 87. Removing an NG tube<br />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 nasopharnyx, you can pull it quickly.)<br />When possible, immediately cover and remove the tube because its sight and odor may nauseate the patient.<br />Assist the patient with thorough mouth care, and clean the tape residue from her nose with adhesive remover.<br />48<br />
    88. 88. Removing an NG tube<br />For the next 48 hours, monitor the patient for signs of GI dysfunction, including <br />Nausea<br />Vomiting<br />Abdominal distention and<br />Food intolerance<br /><ul><li>GI dysfunction may necessitate reinsertion of the tube.</li></ul>49<br />
    89. 89. Special considerations<br />50<br />
    90. 90. Special considerations<br />If the patient has a deviated septum or other nasal condition that prevents nasal insertion, pass the tube orally after removing any dentures, if necessary. Sliding the tube over the tongue, proceed as you would for nasal insertion.<br />When using the oral route, remember to coil the end of the tube around your hand. This helps curve and direct the tube downward at the pharynx.<br />51<br />
    91. 91. Special considerations<br />If your patient is unconscious, tilt her chin toward her chest to close the trachea. Then advance the tube between respirations to ensure that it doesn’t enter the trachea.<br />While advancing the tube in an unconscious patient (or in a patient who can’t swallow), stroke the patient’s neck to encourage the swallowing reflex and to facilitate passage down the esophagus.<br />52<br />
    92. 92. Special considerations<br />While advancing the tube, observe signs that it has 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. <br /><ul><li>If these signs occur, remove the tube immediately. Allow the patient time to rest; then try to reinsert the tube.</li></ul>53<br />
    93. 93. Special considerations<br />After tube replacement, vomiting suggests tubal obstruction or incorrect position. Assess immediately to determine the cause.<br />54<br />
    94. 94. References<br /><ul><li>Lippincott Williams & Wilkins, “Best Practices: Evidence – Based Nursing Procedures”, Second Edition (2007)
    95. 95. Website: Nasogastric tube insertion; Department of Emergency Medicine: University of Ottawa
    96. 96. Website: Radiographic Imaging CEU Source, LLC </li></ul>55<br />
    97. 97. Thank you <br />56<br />

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