Naso-gastric tube insertion

Mem Van BeekClinical EducatorBradford Teaching Hospitals

AIM

To enable the student to understand the principles of safe NG tube use.

Objectives

By the end of this session students should be able to: State:

Types of NG tubes & their uses Indications for insertion Complications Legal aspect around NG tube insertion

Insert a naso-gastric tube safely and competently

Types of NG tubes

Fine –bore feeding tube Ryle’s tube for gastric drainage

Feeding Draining

INDICATIONS

FINE BORE NG TUBE Short term enteral feeding (4-6 weeks)

Malnutrition Head & neck surgery Ca Head & neck / oesophagus Inadequate intake Oral cavity fistulae

To prolong & sustain life

INDICATIONS cont

RYLE NG TUBE To drain gastric contents

Abdominal distension Unconscious pt Major surgery Intestinal obstruction

To stop vomiting & prevent aspiration

Contraindications

Head injury – basilar skull # Rhinorrhea –CSF Obstructing oesophageal ca Epistaxis Feeding above an obstruction Recent gastro oesophageal anastomosis Hx of nasal or sinus surgery occlusions

Cautions

Neck & buccal flap repair Laryngectomy Oesophageal ca Head & neck surgery Uncooperative pts

Complications of NG feeding

Aspiration due to feed regurgitation or incorrect tube placement

Nausea & vomiting due to rapid feeding poor gastric emptying

Diarrhoea Type of feed ie Jevity Gut infection

Complications cont

Constipation inadequate fluid intake immobility use of opiates

Blocked tube inadequate or no flushing of tube administering meds via tube

Unstable BMs ↑BMs esp with high carb feed ↓BMs esp if feed is stopped quickly or interupted

Complications cont

Deranged electrolytes- re feeding syndrome Fluid overload Intestinal obstruction Dislodged tube Weight loss/ gain

Due to feed imbalances – poor regime Excoriation of skin around tube

Risks associated with NG tubes

Pneumothorax Coiling of tube in the throat Parotiditis Retropharyngeal Abscess Sinusitis Acid reflux Aspiration pneumonitis Severe sepsis (the most serious risk)

Legal Aspect

2005 NPSA – 11 deaths due to misplaced NG feeding tubes

Correct & clear documentation National & Local guidelines

Measuring length of feeding tube

From bridge of nose to ear lobe to bottom of xiphisternum

Position of pt during insertion

Equipment required

Tray Fine bore with introducer / Ryle’s tube Receiver Sterile water Glass of water 20ml syringe Tape (hypoallergenic) Lubricating jelly Indicator strips ( pH fix, 0-6, Fisher scientific)

Procedure

Clinically clean procedure Wash hands Introduce self ID patient Gain informed consent Arrange a signal of communication Pt to sit in high Fowler’s position Prepare equipment Measure tube (as previously stated) & mark with

tape.

Procedure

Lubricate tube Check for nostril patency Insert the rounded end of tube into the clearer

nostril & slide it backwards & inwards along the floor of the nose to the nasopharynx.

When tube reaches nasopharynx (back of throat), ask pt to sip & swallow some water using a straw.

Advance the tube through the pharynx (as pt continues to swallow) till the predetermined mark has been reached

If at any point pt shows signs of distress/ cyanosis – remove tube.

Procedure

Secure the tube to nostril & cheek with tape Check the position of the tube to confirm that it is in

the stomach by Check pH Do X-ray of chest & upper abdomen NO OTHER METHODS ARE ACCEPTED (NPSA 2005)

If position is correct; Mark the tube at the exit site & record the tube length in

the notes remove guide wire from fine-bore tube & start feeding per

regime Connect drainage bag to Ryle’s tube for free drainage or

spigot for prn aspiration.

Checking pH

Flush the NG tube with 20ml of air – to clear any substance already in tube

Aspirate 2ml of stomach content and test on pH strip. (blue litmus paper should not be used)

pH should be ≤5.5 (acidic) If checking pH in tube already in place, wait 1hour

after feed or medication as these can affect pH reading.

If pH of >5.5 is obtained – & pt is asymptomatic send for X-ray

REMEMBER

DO NOT use the ‘whoosh’ test DO NOT use blue litmus paper DO NOT use absence of respiratory distress DO NOT monitor bubbling at end of tube DO NOT use appearance of fluid aspirate

NPSA 2005

Document

Date Time Type of tube inserted Reason Length inserted & how it is marked pH of aspirate Nursing instructions