5.2. BASIC CONCEPTS
Anasogastric (NG) tubeis a flexible plastic tube inserted through a nostril, down the posterior oropharynx, and into the stomach or the upper portion of the small intestine. It is typically used for decompression of the stomach for clients with an intestinal obstruction or ileus or for administration of nutrition or medication to clients who are at risk for aspiration or unable to tolerate oral intake. Depending on the intended purpose of the tube, there are different types of NG tubes designed specifically for its use.[1]
Orogastric (OG) tubes have similar indications, monitoring, and care as NG tubes, but they are inserted through the mouth instead of the nose. OG tubes are often preferred for clients receiving mechanical ventilation.
Anatomy and Physiology
The nurse should be familiar with the anatomy and physiology of the nose, pharynx, esophagus, and stomach when caring for clients with NG tubes. See Figure 5.1[2]for an illustration of the nasal cavity and pharynx.
Figure 5.1
Nasal Cavity, Pharynx, and Epiglottis
The nares are the exterior openings to the nasal cavity. Usually, one nare is larger and more patent than the other. A septum, composed of bone and cartilage, divides the right and left nasal cavities. The nasal floor is parallel to the roof of the mouth. The end of the nasal cavity is narrow and ends at the juncture of several bones, including a portion of the cribriform plate, which is a very thin bone that, if fractured, could provide a direct portal into the brain. For this reason, NG tube placement in clients with suspected head trauma may be contraindicated.
The pharynx is a mucous membrane lined tube that begins at the nasal cavity and is divided into three major regions: the nasopharynx, the oropharynx, and the laryngopharynx.
The nasopharynx serves only as an airway. It is a muscular passageway at the beginning of the pharynx, located behind the nasal cavity. It curves to extend behind the oral cavity to become the oropharynx.
The oropharynx is a passageway for both air and food. The oropharynx is bordered superiorly by the nasopharynx and anteriorly by the oral cavity.
The laryngopharynx is inferior to the oropharynx and posterior to the larynx. It continues the route for ingested material and air to the inferior end where the digestive and respiratory systems diverge. Anteriorly, the laryngopharynx opens into the larynx, and posteriorly it enters the esophagus that leads to the stomach. The larynx connects to the trachea and the lungs, so for this reason, great care must be taken when inserting an NG tube to ensure it enters the posterior laryngopharynx and goes into the esophagus, not anteriorly into the trachea and the lungs.
The epiglottis is a cartilaginous flap of connective tissue located at the entrance to the larynx. During swallowing, the larynx moves upward, and the epiglottis closes over the glottis to prevent aspiration of food and fluid into the trachea. Many clinicians use this natural movement during NG tube insertion by asking clients to swallow ice chips or water once the NG tube passes beyond the oropharynx (i.e., the back of the oral cavity). As the client swallows, the rising and falling of the larynx and the opening and closing of the epiglottis can assist passage of the NG tube beyond the laryngopharynx toward the esophagus. The nurse can request the client to tuck their chin to ease this passage.
The esophagus starts at the upper esophageal sphincter and runs down through the diaphragm past the lower esophageal sphincter to the stomach. See Figure 5.2[3]for an illustration of the pharynx, trachea, esophagus, and stomach.
Figure 5.2
Pharynx, Trachea, Esophagus, and Stomach
Indications for NG Tubes
These are the indications for NG tubes[4]:
To decompress the stomach and gastrointestinal (GI) tract (i.e., to relieve distention due to bowel obstruction, ileus, or atony)
To administer nutrition and/or medication
To empty the stomach to prevent aspiration (for example, NG tubes may be inserted in intubated clients to prevent aspiration)
To remove blood from clients with GI bleeding[5]
To obtain a sample of gastric contents to assess bleeding, volume, or acid content
To remove ingested toxins
To give antidotes such as activated charcoal
To give oral radiopaque contrast agents
To provide bowel rest
Bowel Obstruction and Ileus
The most common indication for placement of a nasogastric tube is to decompress the stomach of a client with a distal bowel obstruction or ileus.Bowel obstructionis a mechanical blockage of intestinal contents by a mass, adhesion, hernia, impacted stool, or other physical blockage such as volvulus (i.e., twisting of the stomach or intestine) or intussusception (i.e., one segment of intestine telescopes inside another). Bowel obstructions block the normal passage of bodily fluids such as salivary, gastric, hepatobiliary, and enteric secretions, causing the fluids to build up, resulting in abdominal distension, pain, and nausea. Eventually, the fluids will build up to a point that nausea will progress to emesis, putting the client at risk for aspiration.[6]
Ileusoccurs when there is a nonmechanical decrease or stoppage of the flow of intestinal contents. Ileus is often an unavoidable consequence of abdominal or retroperitoneal surgery but can also be found in severely ill clients with septic shock or mechanical ventilation. An ileus usually manifests itself from the third to the fifth day after surgery and usually lasts 2 to 3 days with the small bowel being the quickest to return to function (0 to 24 hours), followed by the stomach (24 to 48 hours), and lastly the colon (48 to 72 hours). Other causes of ileus may include the following[7]:
Prolonged abdominal/pelvic surgery
Lower gastrointestinal (GI) surgery
Opioid use
Intra-abdominal inflammation (sepsis/peritonitis)
Peritoneal carcinoma
Perioperative complications (pneumonia or abscess)
Bleeding (intraoperative or postoperative)
Hypokalemia
Delayed enteral nutrition or nasogastric (NG) tube placement
NG tube placement is a temporary intervention for bowel obstruction and ileus when normal peristalsis is temporarily altered. It serves to decompress the stomach and keep it empty until normal peristalsis returns. If decompression is needed for more than six weeks, then something more permanent like a jejunostomy tube may be inserted.
Nutrition and Medication Administration
Nasogastric tubes may be placed to administer nutrition or medications for a client who has a functional GI tract but is unable to ingest, chew, or swallow food safely or in adequate amounts.This indication is common for clients who have suffered a cerebrovascular accident (i.e., stroke) that has left them unable to swallow effectively. Nasogastric tubes may be placed for nutritional support while waiting to see how much function the client will recover. If the client does not adequately recover their swallowing ability or will otherwise require long-term nutritional support, then a more permanent feeding tube is placed such as a gastrostomy or jejunostomy feeding tube.[8]
Other examples of conditions where clients have a functioning GI tract but cannot tolerate oral intake are as follows:
Decreased level of consciousness, such as a coma or a sedated client on a ventilator
Following upper gastrointestinal surgery where ananastomosis(i.e., a surgical connection between parts of the intestine) must be protected in the initial postoperative period
During preoperative period to prepare malnourished clients for major abdominal surgery
For many of these indications for NG tubes, an orogastric tube (OG tube) can also be placed. Many of the principles used to manage an NG tube are the same for managing an OG tube, such as checking placement and monitoring for potential complications.
Contraindications for NG Tubes
There are two types of contraindications for any procedure or intervention and are referred to as absolute and relative. An absolute contraindication means the procedure or intervention may produce a life-threatening situation and should be avoided if possible. A relative contraindication means caution should be used because the possibility of an adverse event is possible; therefore, benefits must outweigh the risks.
Absolute contraindications to the placement of an NG tube include significant facial trauma; basilar skull fractures; or recent nasal, throat, or esophageal surgery where attempted placement of a tube via the nares may exacerbate the existing tissue trauma. In some cases of esophageal surgery, such as an esophagectomy, the surgeon will place the NG tube in the operating room and then remove it when indicated; the nurse should not manipulate the NG tube in this case. Esophageal obstruction, such as a neoplasm or foreign object, is also an absolute contraindication to nasogastric tube placement.[9]
Relative contraindications include esophageal trauma, especially if caustic substances were ingested. Coagulation abnormalities or anticoagulation therapy may cause bleeding from the tissue trauma from tube placement. For clients with previous gastric bypass surgery, hiatal hernia repair, or abnormal GI anatomy (such as esophageal varices or strictures), NG tubes should be placed by a provider under endoscopy.[10]
Types of NG Tubes
There are two basic types of NG tubes, those used for decompression and those used for feeding.
For decompression, a double-lumen, rigid tube is used with one large lumen used for suction and a smaller lumen to act as a sump. (A sump allows air to enter to prevent suctioning of the gastric mucosa into the eyelets at the distal tip of the tube or obstruction when the stomach is fully collapsed.) These tubes are often referred to as “Salem Sump.” Their bore size ranges from 6 to 18 French, with those most commonly inserted being 14 to 16 French. A blue pigtail on this type of tube is the air vent, so it should never be clamped, connected to suction, or used for irrigation. See Figure 5.3[11]for an image of a Salem Sump.
Figure 5.3
Salem Sump. Used under Fair Use.
NG tubes used for administration of medications or feeding are single lumen and are softer than those used for decompression. They have a smaller bore with a size ranging from 8 to 12 French. NG tubes placed for feeding or medication administration may be a Levin tube or a Dobhoff tube. A Levin tube is a simple small diameter NG tube. A Dobhoff tube is a special type of NG tube that is small-bore and flexible, so it is more comfortable for the client than a standard NG tube. The tube is inserted with the use of a guide wire, called a stylet, that is removed after correct tube placement is confirmed. A Dobhoff tube also has weight on the end to allow gravity and peristalsis to help advance the end of the tube past the pylorus, providing an additional barrier to reduce aspiration risk of nutrition or medications administered. See Figure 5.4[12]for an image of a Levin tube and Figure 5.5[13]for an image of a Dobhoff tube.
Figure 5.4
Levin Tube
Figure 5.5
Dobhoff Tube With Weighted Tip
NG Tube Insertion
Insertion of an NGT is typically a clean (not sterile), “blind” procedure, meaning the person performing the procedure can’t visualize where the tube is going in the client’s body as they are inserting it. Insertion involves passing the tube through the nose, along the nasal floor, through the pharynx and down the esophagus until the proximal tip of the tube rests in the client’s stomach. See “Checklist: Insert a Nasogastric Tube” for detailed procedural instructions.
NG tubes are inserted and removed by nurses and other health care providers. Due to the invasive nature of the placement process, privately ask the client if they desire visitors to leave the room during placement or removal of the NG tube. Nurses provide the daily care of NG tubes, as well as the administration of nutritional formulas, medications, and other substances through the tube. Nursing management of NG tubes are further described in the “Applying the Nursing Process” section of this chapter. The nurse is also responsible for verifying the NG tube has been accurately placed prior to initial use and before each use thereafter.[14]
Estimating the Depth of NG Tube Placement
Five to seven centimeters posterior to the nares, the nasal sinus connects to the nasopharynx. The length of the pharynx from the base of the skull to the start of the esophagus is 12 to 14 centimeters. The esophagus, from the upper esophageal sphincter to the stomach, is approximately 25 centimeters. The stomach is a highly distensible structure and can vary in length, but the empty stomach is typically about 25 centimeters long. Thus, approximately 55 centimeters of the NG tube is typically inserted in an adult.[15]
There are several methods used to estimate the depth that an NG tube should be placed. A common preprocedural maneuver used to estimate the length of the tube that should be inserted is to measure the tube from the tip of the client’s nose to the earlobe and then against the throat down to the xiphoid process, about 1/2 inch to 1 inch below the sternal notch.[16]
Special Circumstances
Insertion of weighted NG tubes used for feeding, as well as NG tubes for post-GI surgery clients, is performed by specially trained advanced practice nurses, physician assistants, or physicians.
The NG tube inserted for a post-GI surgery client should never be repositioned due to the risk of rupturing a suture line. If the NG tube becomes dislodged, the surgeon should be notified.
If a client is unconscious, gag reflex should be assessed before initiating the procedure. Flex their head forward with your nondominant hand during the procedure as the tube is passed through the larynx. Extra precautions must be taken for clients with head injury to avoid misplacement of the NG tube.
Request assistance prior to starting the procedure based on the client condition. For example, clients who are confused, anxious, at risk for pulling out the tube as it is being inserted, and children often require assistance. Additionally, for pediatric clients it is often helpful to have their parents or caregivers at the bedside. For infants, sucrose may be administered to alleviate discomfort, based on agency policy.
Verifying NG Tube Placement
Insertion of NG tubes is considered a simple procedure, but incorrect placement can lead to client harm and possibly death. The risk of harm and death increases when misplaced tubes are not identified prior to their use. For this reason, placement must be verified immediately after insertion by an X-ray to ensure it has not been inadvertently placed into the trachea and into the bronchi. The nurse should monitor for signs and symptoms of incorrect placement during the procedure, such as coughing, decreased pulse oximetry readings, and cyanosis. If these signs occur, the tube should immediately be withdrawn until normal breathing resumes. See Figure 5.6[17]for an image of an X-ray demonstrating correct placement of an enteral tube in the stomach as indicated by the lower red arrow. (This X-ray also demonstrates an endotracheal tube correctly placed in the trachea as indicated by the top arrow.) After X-ray verification, the tube should be marked with adhesive tape and/or a permanent marker to indicate the measurement on the tube where the feeding tube enters the nares or penetrates the abdominal wall. This number on the tube at the entry point should be documented in the medical record and communicated during handoff reports. At the start of every shift, the nurse should evaluate if the incremental marking or external tube length has changed. If a change is observed, bedside tests such as visualization or pH testing of tube aspirate can help determine if the tube has become dislodged. If in doubt, the provider should be notified and an X-ray repeated to confirm tube location.[18]
Figure 5.6
Placement Verification by X-Ray
After the tube placement is initially verified by X-ray, it is possible for the tube to migrate out of position due to the client coughing, vomiting, and moving. For this reason, the nurse must routinely check tube placement before every use. The American Association of Critical‐Care Nursing recommends that the position of a feeding tube should be checked and documented every four hours and prior to the administration of enteral feedings and medications by measuring the visible tube length and comparing it to the length documented during X-ray verification.[19],[20],[21]
Older methods of verifying tube placement included observing aspirated GI contents or administering air into the tube with a syringe while auscultating (commonly referred to as the “whoosh test”). However, research has determined these methods are unreliable and should no longer be used to verify placement.[22],[23]
Assessing the pH of aspirated gastric contents is a method used to verify placement in some agencies. Gastric aspirate should have a pH of less than or equal to 5.5 using pH indicator paper that is marked for use with human aspirate. However, caution should be used with this method because enteral formula and some medications alter the gastric pH.[24]
Follow agency policy for assessing and documenting tube placement. Additionally, if the client develops respiratory symptoms that indicate potential aspiration, immediately notify the provider and withhold enteral feedings and medications until the placement is verified.
Potential Complications
The most common complications related to the placement of nasogastric tubes are discomfort, sinusitis, or epistaxis, all of which typically resolve spontaneously with the removal of the nasogastric tube.[25]Other complications associated with use of an NG tube range from minor to more severe and may include the following conditions:
Trauma to the nares, larynx, esophagus, and/or stomach during insertion.
Trauma to or erosion of gastric mucosa, especially if gastric suctioning is prolonged.
Mucosal pressure injury of the nares.
Placement-related issues: Inadvertent placement in the trachea that can lead to pleural injury, pneumothorax, tracheobronchial aspiration, pneumonia, and death. Respiratory distress is a medical emergency, and emergency assistance must be obtained immediately.
Esophageal perforation, evidenced by neck or chest pain, dysphagia, dyspnea, subcutaneous emphysema, or hematemesis.
Inadvertent intracranial placement through a fractured cribriform plate.
Knotting of the NG tube around an endotracheal tube or retrograde positioning (i.e., the proximal tip of the tube curves upward through the esophagus).
References
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Patient Safety Movement. (2020).Actionable patient safety solutions (APSS) #15: Nasogastric tube (NGT) placement and verification.https:
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5.3. APPLYING THE NURSING PROCESS
Assessments and Interventions Prior to Insertion of an NG Tube
Prior to the insertion of an NG tube, the following nursing assessments and interventions should be performed:
Review agency policy for inserting and verifying placement of an NG tube.
Verify the provider’s orders.
Review laboratory results to check for coagulopathies or blood dyscrasias. If the client is on anticoagulation therapy, assess their most current INR before performing the procedure and notify the provider of any concerns.
Ask the client if they have any allergies (e.g., to latex, medications, or other substances).
Confirm client history for facial trauma, deviated septum, nasal fractures, or risk of increased intracranial pressure.
Assess the client’s level of consciousness and their ability to participate in the procedure. Request assistance from a colleague as indicated.
Perform a focused abdominal assessment to identify the client’s baseline status. Auscultate bowel sounds and palpate the abdomen for distention, pain, or rigidity.
Assess the nares for obstructions and the surrounding skin. Select the nostril with the best airflow and skin condition.
Provide patient education on the procedure and answer questions.
Provide emotional support and comfort while being aware this is an uncomfortable procedure for the client. It is helpful to have an assistant nearby during this procedure; the assistant can also provide emotional support to the client as needed during the procedure.
Expected Outcomes of the Procedure
These are the expected outcomes related to insertion of an NG tube:
The NG tube is placed without causing trauma.
The correct placement of an NG tube is verified according to agency policy.
The NG tube remains in place, patent, and functional for the duration of therapy.
Assessments and Interventions After Insertion of the NG Tube
Assessments and interventions immediately after insertion of an NG tube include the following[1]:
Observe for signs of misplacement post-insertion, such as circumoral cyanosis, coughing, choking, dyspnea, decreased oxygen saturation level, or vomiting.
Respiratory distress is a medical emergency, and emergency assistance should be obtained.
Strongly consider removing the NG tube if these signs are present as the tube may be lodged in the airway or lungs.
Do not administer fluids or medications via the NG tube until accurate placement has been verified with an X-ray.
Document the following information in the client’s medical record[2]:
Time and date of the procedure
Type and diameter of the NG tube
Number on the tube where it enters the nares and verification that number was communicated during handoff reports
Method(s) used to verify tube placement
Color and consistency of aspirate, including pH of aspirate if assessed
Client’s tolerance of the procedure
Any unexpected client events or outcomes, interventions performed, and notification of the provider
Patient/family education, including topics presented, response to education provided/discussed, and the plan for follow-up education
Routine Nursing Care of Clients with NG Tubes
Clients with NG tubes are at constant risk for developing adverse effects. While caring for clients with NG tubes, nurses monitor risks and adopt strategies for client safety and quality of care.
When working with clients who have NG tubes, nurses perform the following interventions[3]:
Keep the head of the bed 30 degrees or higher.
Clients with NG tubes are at risk for aspiration, especially if they are receiving enteral nutrition. The head of the bed should always be raised 30 degrees or higher to prevent aspiration.
Prevent migration and/or dislodgement of the tube.
The NG tube should be fastened to the client using a securement device and taped/pinned to the client’s gown to prevent the tube from slipping from out of the stomach, migrating into the lungs, or being accidentally removed.
Maintain and promote comfort.
The NG tube constantly irritates the client’s nasal mucosa and can cause discomfort and potential skin breakdown. Ensure that the tube is securely anchored to the client’s nose to prevent excess tube movement and is pinned to the gown in a manner that avoids excessive pulling or dragging. Routinely confirm the NG tube is not pressing against the client’s nares or septum and regularly assess the skin around the tube and securement device for breakdown. The tube should be periodically repositioned in the nares to help prevent pressure injuries. Notify the provider of any concerns.
If the client has abdominal distension or complains of abdominal pain, discomfort, or nausea or begins to vomit, perform the following actions:
If the client is receiving suctioning, verify suction settings are consistent with the provider order, including “continuous” versus “intermittent” suctioning and “low” versus “high” suction level. Check for kinking of the tube from the nare to the suction source.
Some NG tubes have valves that permit delivery of oral agents without disconnecting the tube. Ensure the valve is not turned in a direction that is blocking the tube.
Assess the patency of a tube according to agency policy, typically by irrigating with a 60-mL syringe and 30 mL of tap water. NG tubes are prone to clogging for a variety of reasons. The risk of clogging may result from tube properties (such as narrow tube diameter), the tube tip location (stomach vs. small intestine), insufficient water flushes, aspiration for gastric residual volume, contaminated formula, and/or incorrect medication preparation and administration. To prevent clogging, NG tubes should be flushed a minimum of once per shift or according to provider orders/agency policy. Feeding tubes should be flushed immediately before and after intermittent feedings and medication administration and follow appropriate medication administration practices. Read more information about tube irrigation in the “Basic Concepts of Enteral Tubes” section in the Open RNNursing Skillsbook.
If the client is receiving enteral feedings, monitor for signs of tube feeding intolerance (i.e., abdominal bloating, nausea, vomiting, diarrhea, cramping, and constipation). If cramping occurs during bolus feedings, it can be helpful to administer the enteral nutritional formula at room temperature to minimize or help prevent symptoms.
Perform oral care.
Because one nostril is blocked, clients tend to breathe through their mouth, causing dehydration of the nasal and oral mucosa. Clients often complain of thirst, but they are typically NPO (nothing by mouth) when an NG tube is in place. Oral care keeps the oral mucous membranes moist and helps relieve dryness, as well as preventing infection. Oral care can include rinsing the mouth with cold water or mouthwash, as long as the client does not swallow. Some clients may be permitted to suck on ice chips per provider orders. Lubricant should be applied to the lips and the external nares.
Clients may have throat discomfort. Some providers may prescribe a numbing throat spray but use with caution because it can hinder the gag reflex and increase the risk of aspiration.
Monitor input/output, electrolyte balances, and weight trend.
Because a client with an NG tube is typically NPO, it is important to closely monitor their fluid, electrolyte, and nutritional statuses. They are also at risk for acid/base imbalance. NG tubes used for suctioning place clients at risk for hypokalemia and metabolic alkalosis when large volumes of stomach acid contents are removed from the body.
If the client is receiving suctioning, the drainage amount and color should be documented every shift.
Fluid flushes and enteral feedings should be documented in the Input and Output (I & O) area in the medical record.
Electrolyte and blood glucose levels should be monitored, as ordered, for signs of imbalances.
Daily weights are typically ordered, and weight trends should be monitored by the nurse.
Monitor for potential complications.
Signs of tube dislodgement into the respiratory tract include coughing, shortness of breath, adventitious lung sounds, or decreasing oxygen saturation levels.
Signs of esophageal perforation include neck or chest pain, dysphagia, dyspnea, subcutaneous emphysema, or hematemesis.
Life Span Considerations
When caring for older adults or children with NG tubes, there are additional factors to consider. For example, if the client wears dentures, remove them for the client’s safety and comfort prior to inserting the NG tube.
For pediatric clients, irrigation of an NG tube requires a smaller fluid volume. Check agency policy, but typically the flushing volume is 2 to 5 mL in pediatric patients and 1 mL or less of water in neonates. For neonates, care should be taken to use the appropriate size and type of NG tube to prevent injury to the delicate nasal and gastrointestinal tissues.[4]
Delegation and Collaboration
The task of inserting and maintaining an NG tube cannot be delegated to unlicensed assistive personnel (UAP). However, the nurse can delegate the following actions to UAP under appropriate supervision:
Measuring and recording drainage
Providing oral and nasal hygiene
Anchoring the NG tube to the client’s gown during routine care to prevent displacement
Immediately reporting to the nurse any signs of redness or irritation of the nares
Removal of NG Tube
See “Checklist: Remove an NG Tube” for procedural steps of removing an NG tube.
Note that accidental removal of an NG tube is not a medical emergency. If accidental removal occurs, assess the client and notify the provider.
References
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5.4. CHECKLIST: INSERT A NASOGASTRIC TUBE
*Disclaimer: Always follow agency policy and manufacturer recommendations
Checklist: Insert a Nasogastric Tube[1],[2]
Preparation Before Procedure
The following steps should be taken in preparation for the procedure[3]:
The indication for the procedure, potential complications, and alternative to treatment should be explained to the client by the provider. If an informed consent form is required by agency policy, the nurse should ensure the informed consent form has been signed and is present in the client’s medical record.
Review the client’s medical record for conditions that may contraindicate insertion of an NG tube (e.g., facial trauma or fractures, deviated or swollen nasal septum).
If the nasogastric tube is to be connected to suction, attach the NG tube to the suction tubing and suction container before placement of the tube to minimize the risk of spillage of gastric contents.
Perform a thorough gastrointestinal (GI) assessment.
Gather and prepare equipment. All supplies should be close at hand to minimize unnecessary movement during the procedure. *Note: Topical use of local anesthetics such as lidocaine has not been shown to be useful for NG insertion, but the evidence does show that nebulized lidocaine relieves discomfort and allows for an increased chance of NG tube placement.
Gather the necessary supplies:
Nasogastric tube per provider order
Antireflux valve
Stethoscope
Pulse oximeter
Hypoallergenic tape or agency approved securement device
Cup of water and straw
Clean gloves
Suction equipment (if prescribed by provider)
Penlight
Tongue blade
Water-based lubricant
Oral hygiene supplies
Fluid-impermeable drape or towel
Explain the procedure to the client and family members (if appropriate) according to their individual communication and learning needs. Assess client anxiety regarding insertion of the tube. Answer any questions and provide emotional support as necessary.
Procedure
Verify the provider’s orders for tube insertion and associated premedications.
Perform hand hygiene.
Confirm the client’s identity using at least two patient identifiers and check allergies.
Provide privacy.
Assess the rigidity of the tube. If you need to increase the tube’s flexibility to ease insertion, coil it around gloved fingers for a few seconds or dip it in warm water. If the tube is too flaccid, stiffen it by filling the tube with water and then freezing it or dipping the tube in ice water.
Advise the client they may feel some discomfort as the tube moves through the nose but that the tube will be lubricated to ease its passage. Topical anesthetic and nasal vasoconstricting medications may be administered, as prescribed.
Explain to the client they will be given water to sip once the tube reaches the pharynx. The swallowing action will facilitate passage of the tube and minimize the natural tendency to gag.
Ask the client to identify a signal they will use to communicate with you if it is necessary to stop briefly during the insertion, such as raising their hand.
Raise the bed to waist level.
Perform a focused gastrointestinal assessment.
Because the dominant hand will be used to insert the tube, stand on the client’s right side if right-handed or on the client’s left side if left-handed.
Position the client (in high Fowler’s position) with the head of the bed elevated at least 30 degrees; if this position is contraindicated, consider the reverse Trendelenburg position. Assist the client in positioning their head in a neutral position, neither tilted forward nor backward.
Perform hand hygiene.
Put on nonsterile gloves and other personal protective equipment as indicated.
Assess the client’s nares to determine the best choice for insertion. Use a penlight to visualize nares as needed.
Estimate the insertion length of the tube by measuring from the tip of the nose to the earlobe to the sternal notch of the xiphoid process. Mark this estimated exit point on the tube with a piece of tape or permanent marker.
Drape a fluid-impermeable pad or towel over the client’s chest. Place an emesis basin within reach because the client may gag or vomit during the procedure.
Lubricate the proximal tip of the tube about 2 to 3 inches with water-soluble lubricant.
Encourage the client to hold their head upright. You may wish to support the client’s head with your nondominant hand while inserting the NG tube.
Grasp the end of the tube with the distal end pointing downward, curve it if necessary, and carefully insert it into the most patent nare.
Guide the tube at an angle parallel to the floor of the nasal canal and then gently downward as the tube advances through the nasal passage toward the distal pharynx.
If resistance is met, try to gently rotate the tip until it advances past the nasal passage. If continued resistance is met, don’t force the tube. Instead, withdraw the tube and allow the client to rest, relubricate the tube, and retry or insert the tube in the other nare.
After the tube reaches the oropharynx, have the client flex their head forward and tuck their chin down. Encourage them to sip water through a straw as you slowly advance the tube (unless contraindicated).
As the tube is advanced, monitor the client for cues that might indicate that the tube entered the respiratory tract or the tube kinked or coiled in the oral cavity. If the client appears cyanotic or begins coughing severely during advancement of the tube, pull the NG tube backwards until normal breathing resumes. Severe coughing during tube insertion can indicate inadvertent placement in the trachea or bronchi. Reattempt advancement of the tube after the client begins breathing normally. However, never advance the NG tube against resistance because perforation may occur.
Continue to advance the tube to the predetermined measured length.
Following insertion, clean any excess lubricant from the client’s skin.
Secure the NG tube to the client’s nose using a securement device, tape, or semipermeable transparent dressing. When securing the NG tube, use care to avoid applying undue pressure to tissue to reduce the risk of pressure injuries.
Position the NG tube so the distal end is facing upwards and secure it to the client’s gown according to agency policy. If using a rubber band, place it over the NG tube. Wrap one end of the rubber band behind the NG tube and up through the open half of the rubber band and then continue to pull the end so that the band is tightened around the tube. Use a safety pin to attach the rubber band and NG tube to the client’s gown.
Remove and discard the fluid-impermeable pad or towel.
Discard used supplies in the appropriate receptacle.
Remove and discard gloves and any personal protective equipment worn.
Perform hand hygiene.
Follow agency policy to verify correct placement of the NG tube. Do not instill anything through the NG tube or connect it to suction until correct placement has been confirmed.
After correct placement is verified, document the length of the tube where it exits the nare. If a stylet is present, remove it at this point. Turn on suction, if ordered, to intermittent or continuous suction and typically set it to 30 to 40 mmHg. Ensure the suctioning equipment is working properly.
Provide oral care, discard any used supplies, and then perform hand hygiene.
Keep the head of the bed elevated at least 30 degrees.
In an inpatient setting, help the patient into a comfortable position and place personal items, the tray table, and the call light within easy reach. Make sure the patient knows how to use the call light to summon assistance. To ensure the patient’s safety, raise the appropriate number of side rails and lower the bed to the lowest position. Ensure the bed is locked.
Assess the client’s status and comfort level; reposition as necessary.
Update the client’s plan of care, as appropriate.
Perform hand hygiene.
Document the procedure.
Documentation Cues:
Pre-procedure assessments
Type and size of tube placed
Location of the distal tip of the tube (external measured length of the tube)
Client’s tolerance of the procedure
Confirmation of the tube’s position by X-ray examination
Any unexpected outcome and related nursing interventions performed
Pain assessment and management
View a YouTube video[4]showing an instructor demonstration of this skill:
References
- 1.
Clinical skills: Essentials collection(1st ed.). (2021). Elsevier.↵.
- 2.
Lippincott procedures.http://procedures
.lww.com↵. - 3.
This work is a derivative ofStatPearlsby Sigmon and An and is licensed underCC BY 4.0↵.
- 4.
Chippewa Valley Technical College. (2023, January 5).Inserting a nasogastric tube[Video]. YouTube. Video licensed underCC BY 4.0.https://youtu
.be/_QA5lpxdbBQ↵.
5.5. CHECKLIST: REMOVE AN NG TUBE
*Disclaimer: Always follow agency policy and manufacturer recommendations
Checklist: Remove an NG Tube[1],[2]
Note: An NG tube should be removed if it is no longer required. The removal process is typically quick. Prior to removing an NG tube, verify the provider’s orders for removal. If the NG tube was ordered to remove gastric content, the provider’s order may include a “trial” clamping of the tube for a specified number of hours to verify the client can tolerate its removal. During the trial, the client should not experience any nausea, vomiting, or abdominal distension.[3]
Verify the provider’s orders to remove the NG tube.
Gather the necessary supplies:
Fluid-impermeable pads
20-60 mL syringe
Nonsterile gloves
Stethoscope
Oral hygiene supplies
Tissues
Garbage bag
Verify the client using two patient identifiers.
Explain the procedure to the client.
Place the client in high Fowler’s position.
Perform hand hygiene.
Assess the client’s gastrointestinal function prior to removing the NG tube.
Place a fluid impermeable pad on the client’s chest.
Disconnect the tube from feeding and suctioning if present.
Remove the tape or securement device from the nose.
Unclip the NG tube from the client’s gown.
Verify tube placement and then clear the NG tube by inserting 10 to 20 mL of air into the tube to prevent aspiration of any remaining gastric contents.
Instruct the client to take a deep breath and hold it.
Holding one’s breath closes the epiglottis and prevents aspiration.
Kink the NG tube near the nare and gently pull out the tube in a swift, steady motion, wrapping it in your hand as it is being pulled out. Inspect the tube for intactness. Dispose of the tube in the garbage bag.
Kinking the tubing prevents any residual gastric contents from flowing out of the tube upon removal.
Offer tissue and/or clean the nares for the client.
Offer oral care for client comfort and to prevent transmission of microorganisms.
Discard used supplies, remove gloves, and perform hand hygiene.
In an inpatient setting, help the patient into a comfortable position and place personal items, the tray table, and the call light within easy reach. Make sure the patient knows how to use the call light to summon assistance. To ensure the patient’s safety, raise the appropriate number of side rails and lower the bed to the lowest position. Ensure the bed is locked.
Perform hand hygiene.
Document the procedure and assessments.
After tube removal, continue to monitor the client for signs of gastrointestinal (GI) dysfunction, including nausea, vomiting, abdominal distention or discomfort, and food intolerance. Notify the provider of GI dysfunction because reinsertion of the NG tube may be required.
Documentation Cues:
Client’s GI assessment and status before tube removal
Date and time of NG tube removal; the color, consistency, and any amount of gastric drainage
Visual inspection and intactness of the tube upon removal
Client tolerance of the procedure
Client and family (if applicable) education, their understanding of that teaching, and any need for follow-up teaching.
Any type of unexpected outcome and the interventions performed
View a YouTube video[4]showing an instructor demonstration of this skill:
References
- 1.
Clinical skills: Essentials collection(1st ed.). (2021). Elsevier.↵.
- 2.
Lippincott procedures.http://procedures
.lww.com↵. - 3.
This work is a derivative ofClinical Procedures for Safer Patient Careby British Columbia Institute of Technology and is licensed underCC BY 4.0↵.
- 4.
Chippewa Valley Technical College. (2023, January 5).Removing a nasogastric tube[Video]. YouTube. Video licensed underCC BY 4.0.https://youtu
.be/BYM1nOdIzoM↵.
5.7. LEARNING ACTIVITIES
Exercises
(Answers to the exercises are located in the Answer Key at the back of the book).
Case Study #1
Caroline, age 92, visits her health care provider for a follow-up visit with her son Brian. You take Caroline’s vitals prior to the visit and find her to be hypotensive and bradycardic. She is slow to respond to questions, and Brian answers most of the questions you have for her. Brian says, “I’m worried about mom; that’s why I asked for this appointment. I haven’t seen her since Christmas two weeks ago, but she looks as if she has withered away to nothing in that time.”
You note that since her last visit six months ago, she has had a 20-pound weight loss, and her BMI today is 16.2. Caroline lives alone in an apartment in an assisted living facility; her husband passed five years ago. Brian is her only child.
Brian states, “I thought she was doing so well. I haven’t been told that she wasn’t eating, but when I visited yesterday, she refused to eat any lunch or dinner, and only ate a half piece of toast at breakfast.”
When you ask Caroline how she’s feeling, she says, “I just don’t feel like eating anymore. I know that I’m healthy, but my appetite is not there. I’m not ready to give up.” She smiles, “I’m still a feisty 92 years young.”
Caroline’s health care provider admits her to the hospital to start NG tube feedings.
- 1.
What can you provide for client education regarding the NG tube?
- 2.
What are the maintenance care priorities for care of the NG tube?
- 3.
Are there any specific concerns related to Caroline’s need for an NG tube that should be monitored or addressed? What will you consider as you prepare for placement of the NG tube?
- 4.
What is the purpose of the NG tube?
- 5.
How often should an NG tube be assessed?
- 6.
What cues would indicate further assessment of the NG tube and the client?
- 7.
What type of technique is used to insert the NG tube?
Test your knowledge using a NCLEX Next Generation-stylequestion. You may reset and resubmit your answers to this question an unlimited number of times.
