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8/9/2019 Nasogastic ion New

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NASOGASTIC INTUBATIONNASOGASTIC INTUBATIONLecture DemonstrationLecture Demonstration

Ariel R. Sinco, RN, MNAriel R. Sinco, RN, MN

Marivic M. Suguitan, RN, MNMarivic M. Suguitan, RN, MN

Leila C. Gutierrez, RNLeila C. Gutierrez, RN


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DEFINITIONDEFINITION

is a medicalis a medical

processprocess

involving theinvolving theinsertioninsertion

of a plastic tubeof a plastic tube

through thethrough the nosenose,,past thepast the throatthroat,,

and down intoand down into

thethe stomachstomach..


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INDICATIONS:INDICATIONS:

To decompress the abdomen beforeTo decompress the abdomen beforeand after surgery.and after surgery.

Liquid feedings (gavage) andLiquid feedings (gavage) and

medications for patient who cannotmedications for patient who cannotswallow and eat by mouth.swallow and eat by mouth.

To wash out (lavage) the stomach.To wash out (lavage) the stomach.


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Prevent or relieve nausea andPrevent or relieve nausea and

vomiting.vomiting.

Treat patient with mechanicalTreat patient with mechanical

obstruction and bleeding withinobstruction and bleeding withinthe GI tract.the GI tract.

Obtain a specimen from gastricObtain a specimen from gastric

secretions for diagnostic studiessecretions for diagnostic studies..


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CONTRAINDICATIONSCONTRAINDICATIONS

The use of nasogastric intubation isThe use of nasogastric intubation iscontraindicated (inadvisable) in patientscontraindicated (inadvisable) in patients

with base of skull fractures, severe facialwith base of skull fractures, severe facial

fractures especially to the nose andfractures especially to the nose andesophagitis with stricture and/oresophagitis with stricture and/or

obstructed airway.obstructed airway.

The use of an NG tube is alsoThe use of an NG tube is also

contraindicated in patients who have hadcontraindicated in patients who have hadgastric bypass surgery.gastric bypass surgery.


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Types ofTubes:Types ofTubes:

Levin tubeLevin tube-- single lumen gastric tube used tosingle lumen gastric tube used to

remove stomach contents and provide feedingremove stomach contents and provide feeding

SalemSalem--sump double lumen tubesump double lumen tube-- most frequentlymost frequently

used tube for decompression with suctionused tube for decompression with suction

Sengstaken blakemore tubeSengstaken blakemore tube-- 3 lumen gastric3 lumen gastric

tube with inflatable esophageal balloon, stomachtube with inflatable esophageal balloon, stomach

balloon and gastric suction lumen used forballoon and gastric suction lumen used for

bleeding esophageal varices.bleeding esophageal varices.

Esophageal balloon should be inflated for 48 hrs onlyEsophageal balloon should be inflated for 48 hrs only

to prevent tissue necrosis.to prevent tissue necrosis.


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Materials:Materials:

Nasogastric tube of appropriateNasogastric tube of appropriatesize (8 to 18 French)size (8 to 18 French)

StethoscopeStethoscope

Suction Apparatus(for irrigationSuction Apparatus(for irrigation

only)only) Glass of water with strawGlass of water with straw

Normal Saline SolutionNormal Saline Solution

Bath towelBath towel

Small basin filled with ice or warmSmall basin filled with ice or warmwater (optional)water (optional)

Asepto bulb syringe orToomeyAsepto bulb syringe orToomeysyringesyringe

Disposable glovesDisposable gloves


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Safety pin and Rubber band ClampSafety pin and Rubber band Clamp

Tape (1 inch wider)Tape (1 inch wider)

WaterWater--soluble lubricantsoluble lubricant

Emesis BasinEmesis Basin

Tongue bladeTongue blade

Flashlight (optional)Flashlight (optional)

TissuesTissues


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INSERTING NASOGASTRICINSERTING NASOGASTRIC

TUBETUBE1.1. Check physicians order for insertionCheck physicians order for insertion

of Nasogastric tube.of Nasogastric tube.

2.2. Explain procedure to client.Explain procedure to client.3.3. Gather equipment.Gather equipment.

4.4. If nasogastric tube is rubber, place itIf nasogastric tube is rubber, place it

in a basin with ice for 5 to 10 minutesin a basin with ice for 5 to 10 minutesor place a plastic tube in warm water.or place a plastic tube in warm water.


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5.5. Assess clients abdomen.Assess clients abdomen.

6.6. Wash your hands. Don disposableWash your hands. Don disposable

gloves.gloves.

7.7. Assist the client to high FowlersAssist the client to high Fowlers

position, and drape his chest with bathposition, and drape his chest with bath

towel or disposable pad. Have emesistowel or disposable pad. Have emesis

basin and tissues handy.basin and tissues handy.


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8.8. Check the nares for patency byCheck the nares for patency by

asking the client to occlude oneasking the client to occlude onenostril and breathe normally throughnostril and breathe normally through

the other. Select the nostril throughthe other. Select the nostril through

which air passes more easily.which air passes more easily.


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9.9. Measure the distance to insert theMeasure the distance to insert the

tube by placing tip of tube attube by placing tip of tube at

clients nostril and extending to tipclients nostril and extending to tip

of earlobe and then to tip of theof earlobe and then to tip of the

xyphoid process. Mark tube with axyphoid process. Mark tube with apiece of tape.piece of tape.

10.Lubricate the first 1010.Lubricate the first 10 20 cm. (420 cm. (4

8 inches) of the tube with a water8 inches) of the tube with a water--soluble lubricant.soluble lubricant.


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11.Ask the client to lift his head,11.Ask the client to lift his head,

and insert the tube into the nostriland insert the tube into the nostril

while directing the tube downwardwhile directing the tube downwardand backward. The client mayand backward. The client may

gag when the tube reaches thegag when the tube reaches the

pharynx.pharynx.


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12. Instruct the client to keep head in12. Instruct the client to keep head in

upright or normal eating position.upright or normal eating position.Encourage the patient to swallow evenEncourage the patient to swallow even

if no fluids are permitted or with theif no fluids are permitted or with the

help of drinking in a glass of waterhelp of drinking in a glass of waterusing a straw.using a straw.

Advance the tube in a downward andAdvance the tube in a downward and

backward direction when the clientbackward direction when the clientswallows. Stop when the clientswallows. Stop when the client

breathesbreathes


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Provide tissues for tearing or watering ofProvide tissues for tearing or watering of

eyes. If gagging and coughing persist,eyes. If gagging and coughing persist,

check placement of tube with a tonguecheck placement of tube with a tongue

blade and flashlight.blade and flashlight.

Keep advancing the tube until the tapeKeep advancing the tube until the tapemarking is reached. Do not use force.marking is reached. Do not use force.

Rotate the tube if it meets resistance.Rotate the tube if it meets resistance.


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13. Discontinue the procedure and13. Discontinue the procedure and

remove the tube if there are signs ofremove the tube if there are signs ofdistress, such as gasping, coughing,distress, such as gasping, coughing,

cyanosis, and the inability to speak orcyanosis, and the inability to speak or

hum.hum.


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NGT gone WRONGNGT gone WRONG


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14. Determine that the tube is in the14. Determine that the tube is in the

client's stomach (these methods areclient's stomach (these methods are

appropriate for largeappropriate for large--bore tubes butbore tubes butmay be ineffective to checkmay be ineffective to check

placement of small bore tube.)placement of small bore tube.)


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a. Put a 10a. Put a 10 20 ml. of air in syringe and20 ml. of air in syringe and

inject air into the tube. Simultaneouslyinject air into the tube. Simultaneously

auscultate over the epigastric area with aauscultate over the epigastric area with a

stethoscope.stethoscope.

Attach the syringe to the end of the tubeAttach the syringe to the end of the tubeand aspirate 10 to 20 ml. of stomachand aspirate 10 to 20 ml. of stomach

contents. Measure the pH of aspirated fluid.contents. Measure the pH of aspirated fluid.

Gastric phGastric ph-- usually 4

Respiratory phRespiratory ph-- usually > 5.5usually > 5.5


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15.Secure the tube with a tape to15.Secure the tube with a tape to

the clients face. Be careful not tothe clients face. Be careful not to

pull the tube too tightly against thepull the tube too tightly against the

nose:nose:

a. Cut a 4a. Cut a 4--inch piece of tape and splitinch piece of tape and split

bottom 2 inches.bottom 2 inches.

b. Place unsplit end over bridge ofb. Place unsplit end over bridge of

clients nose.clients nose.

c. Wrap split ends under the tubingc. Wrap split ends under the tubingand up and over onto the nose.and up and over onto the nose.


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16. Attach tube to suction or16. Attach tube to suction or

clamp the tube with a screwclamp the tube with a screw--

type clamp, according to thetype clamp, according to the

physicians orders.physicians orders.


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17. Secure tube to the clients17. Secure tube to the clients

gown by using a rubber bandgown by using a rubber bandor tape and a safety pin. Ifor tape and a safety pin. If

doubledouble--lumen tube is used,lumen tube is used,secure vent above stomachsecure vent above stomach

level. Attach at shoulder level.level. Attach at shoulder level.


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18. Wash hands. Remove all18. Wash hands. Remove all

equipment and make clientequipment and make client

comfortable.comfortable. 19. Record the insertion19. Record the insertion

procedure, type and size ofprocedure, type and size of

tube, description of gastrictube, description of gastriccontents, and clients response.contents, and clients response.


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ADMINISTERING A TUBEADMINISTERING A TUBE

FEEDINGFEEDING

Equipments:Equipments:

Tube Feeding at room temperatureTube Feeding at room temperature

StethoscopeStethoscope

Asepto orToomey syringe, feeding bagAsepto orToomey syringe, feeding bagor prefilled tube feeding , Enteralor prefilled tube feeding , Enteralfeeding pump (ifIV pole ordered)feeding pump (ifIV pole ordered)

ClampClamp

Disposable pad or towel

Disposable pad or towel

WaterWater

Sterile gauzeSterile gauze

Rubber bandRubber band


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Procedure:Procedure:1.1. Explain procedure to client.Explain procedure to client.

2.2. Assemble equipment. CheckAssemble equipment. Check

amount, concentration, type andamount, concentration, type and

frequency of tube feeding on clientsfrequency of tube feeding on clientschart.chart.

3.3. Wash your hands. Warm the feedingWash your hands. Warm the feeding

to room temperature.to room temperature.


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4.4. Position client with head of bedPosition client with head of bedelevated at least 30 degrees or aselevated at least 30 degrees or asnear as normal position for eating asnear as normal position for eating aspossible.possible.

5.5. Unpin tube from clients gown andUnpin tube from clients gown andcheck to see that the nasogastriccheck to see that the nasogastric

tube is properly located in thetube is properly located in thestomach using the 3 waysstomach using the 3 waysmentioned earlier.mentioned earlier.


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6.Aspirate all gastric contents with6.Aspirate all gastric contents with

syringe and measure. Returnsyringe and measure. Return

immediately through tube andimmediately through tube andproceed with feeding if amount ofproceed with feeding if amount of

residual does not exceed policy ofresidual does not exceed policy of

agency or physicians guideline.agency or physicians guideline.Disconnect syringe from tubingDisconnect syringe from tubing


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Intermittent FeedingsIntermittent Feedings

7. When using Asepto orT

oomey7. When using Asepto orT

oomeysyringe:syringe:

Remove plunger or bulb from syringeRemove plunger or bulb from syringeand attach syringe to tube that hasand attach syringe to tube that hasbeen pinched with finger andbeen pinched with finger and

introduce the prescribed amountintroduce the prescribed amountslowly.slowly.

Hold the syringe about 12 inchesHold the syringe about 12 inchesabove the stomach. Allow solution toabove the stomach. Allow solution to

run in by gravity. Raise the syringe torun in by gravity. Raise the syringe toincrease the rate of flow, and lowerincrease the rate of flow, and lowerthe syringe to decrease the rate ofthe syringe to decrease the rate offlow.flow.


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Do not let the syringe emptyDo not let the syringe empty

while introducing thewhile introducing the

nourishment.nourishment.

Introduce 30Introduce 30 60 ml. (160 ml. (1 2 oz.)2 oz.)

of water into the tube after theof water into the tube after the

nourishment is introduced.nourishment is introduced.

Clamp the tube immediatelyClamp the tube immediately

after the nourishment and waterafter the nourishment and water

are instilled. Disconnect theare instilled. Disconnect the

syringe and cover end of tubingsyringe and cover end of tubingwith gauze secured with rubberwith gauze secured with rubber

band.band.


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8. When using a feeding bag:8. When using a feeding bag:

Hang bag on IV pole and adjust toHang bag on IV pole and adjust toabout 12 inches above the stomach.about 12 inches above the stomach.

Clamp tubing and pour formula intoClamp tubing and pour formula into

the bag. Release clamp enough tothe bag. Release clamp enough to

allow formula to run through theallow formula to run through thetubing. Close clamp.tubing. Close clamp.

Attach tubing to feeding tube, openAttach tubing to feeding tube, open

clamp, and regulate drip according toclamp, and regulate drip according to

physicians order.physicians order.


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Add 30Add 30 60 ml. (160 ml. (1 2 oz.) of2 oz.) of

water to feeding bag whenwater to feeding bag whenfeeding is almost completed andfeeding is almost completed and

allow to run through tube.allow to run through tube.

Clamp the tubing immediatelyClamp the tubing immediately

after water has been instilled.after water has been instilled.

Disconnect from tube. ClampDisconnect from tube. Clamp

tube and cover end with gauzetube and cover end with gauze

secured with a rubber band.secured with a rubber band.


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REMOVING A NASOGASTRIC TUBEREMOVING A NASOGASTRIC TUBE

Materials:Materials:

TissuesTissues

Normal saline solution for irrigation (optional)Normal saline solution for irrigation (optional) Bath towel disposable padBath towel disposable pad

Clean disposable glovesClean disposable gloves

Disposable plastic bagDisposable plastic bag 50 ml. syringe (optional)50 ml. syringe (optional)


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Procedure:Procedure:

1.1. Check physicians order for removal ofCheck physicians order for removal of

nasogastric tube.nasogastric tube.

2.2.Ex

plain procedure to client and assist toEx

plain procedure to client and assist tosemisemi--Fowlers positionFowlers position

3.3. Gather equipment.Gather equipment.

4.4. Wash your hands. Do clean disposableWash your hands. Do clean disposable

gloves.gloves.


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5.5. Place towel or disposable pad acrossPlace towel or disposable pad across

clients chest. Give tissues to client.clients chest. Give tissues to client.6.6. If present, turn off the suction andIf present, turn off the suction and

disconnect the tube . Unpin tube fromdisconnect the tube . Unpin tube from

clients gown and carefully removeclients gown and carefully remove

adhesive tape from clients nose.adhesive tape from clients nose.

7.7. Attach syringe and flush with 10 ml. normalAttach syringe and flush with 10 ml. normal

saline solution or clear with 30 to 50 cc ofsaline solution or clear with 30 to 50 cc of

air (optional).air (optional).


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8.8. Instruct client to take a deep breathe andInstruct client to take a deep breathe and

hold it.hold it.

9.9. Clamp tube with fingers by doubling tube inClamp tube with fingers by doubling tube in

itself. Quickly and smoothly withdraw theitself. Quickly and smoothly withdraw the

tube while clients holds breathe.tube while clients holds breathe.

10.10.Place tube in disposable plastic bag.Place tube in disposable plastic bag.

Remove gloves and place in bag.Remove gloves and place in bag.

11.11.Offer mouth care to client and make clientOffer mouth care to client and make client

comfortable.comfortable.


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12.12.Measure nasogastric drainage. RemoveMeasure nasogastric drainage. Remove

all equipments and dispose according toall equipments and dispose according to

agency policy. Wash your hands.agency policy. Wash your hands.

13.Record removal of tube, clients13.Record removal of tube, clients

response, and measurement of drainage.response, and measurement of drainage.


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NursingManagement of patientNursingManagement of patient

with NGT in placewith NGT in place

Provide patient as much comfort asProvide patient as much comfort aspossible.possible.

Tubes should be properly cleaned beforeTubes should be properly cleaned beforeand after feeding to remove crystals thatand after feeding to remove crystals thatlater form into dried mucus.later form into dried mucus.

The teeth should be brushed even if

The teeth should be brushed even ifpatient is not eating to prevent bacterialpatient is not eating to prevent bacterial

action in the mouth.action in the mouth.


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Provide anesthetic lozenges or garglesProvide anesthetic lozenges or gargles

to prevent sore throat from the presenceto prevent sore throat from the presence

of the tube.of the tube.

Frequent oral hygiene will also increaseFrequent oral hygiene will also increase

the patients comfort by removing debristhe patients comfort by removing debris

and stimulating salivation.and stimulating salivation.


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Additional TIPSAdditional TIPS

about tube feedings:about tube feedings:

Position the person so that hePosition the person so that he

or she is sitting up, or at leastor she is sitting up, or at leastso the upperso the upper--body is abovebody is above

the level of the stomach.the level of the stomach.


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about tube feedings:about tube feedings:Practice good sanitation. Wash yourPractice good sanitation. Wash your

hands before handling the feedinghands before handling the feeding

equipment. Wash feeding bags withequipment. Wash feeding bags with

water. Do not use soap, as it willwater. Do not use soap, as it will

stick to the inside of the bag and getstick to the inside of the bag and getinto the formula. This can causeinto the formula. This can cause

diarrhea and other unpleasantdiarrhea and other unpleasant

consequences.consequences.


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about tube feedings:about tube feedings:Feedings should be given at roomFeedings should be given at room

temperature to minimize risk of crampingtemperature to minimize risk of cramping

and/or diarrhea. Open cans of formulaand/or diarrhea. Open cans of formulacould be kept in the refrigerator, andcould be kept in the refrigerator, and

discarded if not used within 24 hours.discarded if not used within 24 hours.

They should be taken out 15They should be taken out 15--20 minutes20 minutesbefore a feeding and allowed to warm upbefore a feeding and allowed to warm up

to room temperature.to room temperature.


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Always flush the feeding tubeAlways flush the feeding tube

with water after a feeding.T

hiswith water after a feeding.T

hiswill help to prevent the patientwill help to prevent the patient

from getting dehydrated. It willfrom getting dehydrated. It will

also prevent the food fromalso prevent the food fromgetting clogged.getting clogged.


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If medications are to be run downIf medications are to be run down

the feeding tube, always be surethe feeding tube, always be surethey are finely crushed. Flush thethey are finely crushed. Flush the

tube with water to wash themtube with water to wash them

down.down.


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about tube feedings:about tube feedings: If the tube seems to be clogged and a smallIf the tube seems to be clogged and a small

flush of water isn't effective, a flush of aboutflush of water isn't effective, a flush of about

100cc of cola may do the trick. You can also100cc of cola may do the trick. You can alsotry dissolving a quarter teaspoon of meattry dissolving a quarter teaspoon of meat

tenderizer in a teaspoon of water and placingtenderizer in a teaspoon of water and placing

it into the tube. Wait five minutes beforeit into the tube. Wait five minutes before

flushing again. If none of these strategiesflushing again. If none of these strategies

work, contact your health care provider(s) forwork, contact your health care provider(s) for

advice.advice.


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Thank you for listeningThank you for listeningHave a nice dayHave a nice day