Inserting a nasogastric tube
Before nasogastric tube insertion, check the provider’s orders and the patient’s care plan. Assess relevant diagnostic data such as coagulation studies and verify the patient’s history. Patients at high risk for complications, such as those with a history of craniofacial surgery or trauma, may require special insertion techniques or equipment (fluoroscopy). Be sure to discuss any contraindications with the provider. Explain the purpose of the tube to the patient and let her know that discomfort is likely as the tube passes. Agree on a signal the patient can use if she wants you to stop briefly during the procedure.
Inspect each naris for patency, noting any polyps, irritated mucosa, or other problems that may complicate insertion. Have the patient breathe through one naris at a time; select the more patent naris for tube insertion. Test the patient’s gag reflex to ensure adequate swallowing if you plan to use water during the procedure. This helps identify patients who may be at risk for aspiration during insertion. Use water cautiously or avoid it for patients who do not have an adequate gag reflex. Patients may experience transient nausea as the tube’s tip passes down the back of the throat. Be sure to have the suction equipment available in case the patient vomits. Ensure that an emesis basin and facial tissues are within the patient’s reach. Place the patient in a high-Fowler’s position and drape a towel or disposable pad across her chest to protect her clothing and linen.
If prescribed, don gloves and apply a topical anesthetic before inserting the tube to provide effective pain relief, to reduce the risk of nausea and vomiting, and to promote successful passage of the nasogastric tube. Lidocaine gel is often used to eliminate sensation in the nasal mucosa. Viscous lidocaine (10 mL of 2%% oral solution) can be instilled in the naris while the patient’s head is tilted backwards. Ask the patient to sniff and swallow the medication so that it can anesthetize the nasal and oropharyngeal mucosa. For children, do not exceed 4 mg/kg of lidocaine. Wait 5 to 10 minutes to ensure an adequate anesthetic effect. Alternatively, lidocaine can be given by nebulizer via a face mask (1%% or 4%%; administer less than 4 mg/kg and do not exceed 200 mg per dose for adults). To minimize allergic reactions, a preservative-free lidocaine (intravenous lidocaine) can be prescribed. An anesthetic spray that contains benzocaine or tetracaine/benzocaine/butyl aminobenzoate combination can be applied to the nasal and oropharyngeal mucosa, although incidents of methemoglobinemia have been reported. Be sure to follow your facility’s policies and procedures for using these medications. Having the patient hold ice chips in her mouth for a few minutes can have a similar effect. After anesthetizing the patient’s mucosa, prepare the equipment for nasal intubation.
Determine the length of the tube to be inserted by measuring the nasogastric tube from the tip of the patient’s ear lobe to the tip of the nose, then to the xiphoid process. When using a dual-purpose tube (one that is used both for gastric decompression and for enteral feeding), add 10 to 12 inches to allow the distal end to reach the duodenum or jejunum. Mark the tubing with adhesive tape or note the striped markings already on the tube. Lubricate the tip of the tube with water-soluble lubricant. Encourage the patient to breathe deeply through her mouth. Gently insert the tube into the nostril and advance it toward the posterior pharynx. Have her tilt her head forward and encourage her to drink water slowly. Advance the tube without using force as the patient swallows until the desired tube length is inserted. If, at any time, the patient experiences respiratory distress, is unable to speak, or has significant nasal hemorrhaging or if the tube meets resistance, stop advancing the tube and withdraw it.
Temporarily tape the tube to the patient’s nose, then assess the tube’s placement either radiographically, magnetically, with pH testing, or with capnography, depending on your facility’s protocol. The gold standard for ascertaining accurate placement of the tube is radiographic confirmation. Also, determine placement by aspirating fluid from the tube at the time of the insertion and testing its pH. If the pH is 0 to 5, the tube is most likely in the stomach. Auscultation over the stomach while air is irrigated through the nasogastric tube is not a reliable method of assessing placement because you can also hear air over the stomach if the tube has been inserted in the lung. If fluid is to be administered though the tube, radiographic confirmation is strongly recommended.
After confirming the tube’s placement in the stomach, apply a skin barrier and then secure the tube by taping it to the bridge of the patient’s nose or by using a tube attachment device. Anchor the tube to the patient’s gown. Clamp the end of the tube or attach it to suction, as prescribed. If the tube has multiple lumens, be sure to label each lumen appropriately according to its intended use. Discard any waste in the appropriate receptacle. Ensure that the patient is comfortable and then document the procedure.
References
Craven, R. F., & Hirnle, C. J. (2007). Fundamentals of nursing: Human health and function (5th ed.). New York: Lippincott Williams & Wilkins. pp. 1139-1145.
Kowalak, J. P. (Ed.). Lippincottï’s nursing procedures (5th ed.). New York: Lippincott Williams & Wilkins. pp. 657-670.
Shlamovits, G. Z., & Shah, N. R. (2007). Nasogastric tube. Retrieved May 29, 2008, from www.emedicine.com/proc/TOPIC80925.HTM
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2008). Brunner & Suddarthï’s textbook of medical-surgical nursing (11th ed.). New York: Lippincott Williams & Wilkins. pp. 1174-1181.
Smith, S. F., Duell, D. J., & Martin, B. C. (2008). Clinical nursing skills (7th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. pp. 652-662.