Gudelines for Nasogastric tube insertion

Application of Guidelines

These guidelines are applicable to allpatients:_ Neonates_ Children_ Adults

Guideline Sections

Section 1: Ethical considerations prior tonasogastric tube insertion.Section 2: The procedure for nasogastric tubeinsertion.Section 3: The procedure for checking the positionof a nasogastric tube after insertion.

Section 1

Ethical ConsiderationsPrior to NGT Insertion

Information Giving & Informed ConsentInform the patientProcedureReason for insertionImplications after insertionInformed consentConfidentialityRefusal of procedurePatient has a right to refuse treatment.

Background Information

“Deaths spark alert on NG tube checks”(Nursing Times, 1st March, 2005).

Most health care professionals considerNG tube placement as a routine, low riskprocedure as it is a daily procedure onmost units.

Yet, a misplaced NG tube can havedisastrous consequences even leading tothe death of a patient!

The Process of swallowing

Nasogastric Tube In Situ

Correctly Placed NG Tube

NG Tube In Right Lung

NG Tube After Trauma

Section 2

The correct procedure ofnasogastric tubeinsertion

Choosing a Nasogastric Tube

According to:the use for which indicatedAge of patientFunction of tubethe length of time that the patient would beusing the tubethe material of the tubeRead instructions on the back of the packing

Equipment for NGT insertion

1. Clean tray

2. NG tube3. Gauze swab4. Lubricating jelly5. Hypoallergenictape6. 50 ml syringe(funnel-tipped)7. Inch tape8. pH Indicator strips9. Receiver10. Spigot11. Non-Sterile gloves12. Disposable faceMask

Procedure of NG Tube Insertion

1. Explain and discuss the procedure withthe patient To ensure that the patient understands theprocedure and gives his/her validconsent.

2. Arrange a signal by which the patient cancommunicate if s/he wants the nurse tostop.The patient is often less frightened if s/hefeels able to have some control over theprocedure.

3. Assist the patient to sit in a semi-uprightposition in the bed / chair. Supporthis/her head with pillows.Note: The head of the patient should not betilted backwards or forwards. To allow for easy passage of the tube. Thisposition enables easy swallowing andensures that the epiglottis is notobstructing the oesophagus.

4. Using hypoallergenic tape,mark the distance whichthe tube is to be passed bymeasuring the distance onthe tube from the bridge ofthe patient’s nose aroundthe ear lobe and down tothe bottom of thexiphisternum. Measure thelength of tube in cm thatremains out of the nostril To indicate the length of tube required forentry into the stomach and to ensure thatthe tube remains in the correct position.Remember:The markings on the NGT:Mark 1 – 45cmMark 2 – 55cmMark 3 – 65cmMark 4 – 75cm

5. Wash hands with soap and water, andassemble the equipment required. Puton non-sterile gloves.To minimise cross-infection.

6. Check the patient’s nostrils for anyvisible obstructions. Clear nostrils ifnecessary.To identify any obstructions liable to preventintubation.

7. Lubricate about 15-20cm of the tube witha thin coat of lubricating jelly (waterbased)that has been placed on a gauzeswab.To reduce the friction between the mucousmembranes and the tube

8. Insert the proximal end of thetube into the clearer nostriland slide it backwards andinwards along the floor of thenose to the nasopharynx.If an obstruction is felt, withdrawthe tube and try again in aslightly different direction oruse the other nostril. To facilitate the passage of the tube byfollowing the natural anatomy of thenose.

9. As the tube passes down into thenasopharynx, ask the patient to startswallowing. The swallowing action closes the epiglottis,enabling the tube to pass down into theoesophagus.

10. Advance the tube through the pharynx asthe patient swallows until the tapemarkedtube reaches the point of entryinto the external nares.If the patient shows signs of distress, e.g.gasping or cyanosis, remove the tubeimmediately. Distress may indicate that the tube is in thetrachea or bronchus

11. Check the position of theNG tube as indicated inthe Nasogastric TubeInsertion Guidelines –Section 3.To make sure that the NG Tube is in thestomach.

12. Secure the tube to the nostril withadherent dressing tape.If this is contraindicated, a hypoallergenictape should be used.An adhesive patch (if available) will securethe tube to the cheek. Distress may indicate that the tube is in thebronchus.

Section 3

Checking theposition of the nasogastrictube after insertion

Most reliable (Golden Standard):A chest or abdominal X-ray.Less reliable:pH sensitive paper.Least reliable and should not be used (The RoyalMarsden Clinical Nursing Procedures, 6th Edition, 2005) & N.H.S.(2007):Examination of aspirateBlue litmus paperAuscultationSigns of respiratory distress

pH Indicator Strips

pH ≤ 4 confirms NGT in stomachpH ≥ 6 indicates NGT in lungs or smallBowel

pH-Raising Drugs

The following drugs can give a high pHresult despite the tube being in theappropriate position:H2 blockers e.g. Cimetidine (Tagamet),Ranitidine (Zantac).Protein-pump inhibitors (PPI) e.g.Omeprazole, Nexium.Antacids e.g. milk of magnesia, Aludrox.

First-Time Insertion

When a patient has a NG tube insertedfor the first time, one must:Check if patient is on PPIs, H2 blockers orantacidsCheck position with pH indicator paper fora gastric aspirate with a pH ≤ 4Note and document the length of the tubethat remains out of the patient’s nostril (onappropriate sheet)Inform Clinical Nutrition Nurses

Please note:If NG tube insertion is not successful orpostponed, the patient should be placedon some alternative kind of hydration,such as intravenous hydration.

If on PPIs, H2 blockers and antacids:Follow the NG tube insertion procedureTake a Chest X-Ray each time a NG tubeis inserted

When To Check Tube Position

1. Following initial insertion2. Before administering each bolus feed

3. Before giving medication4. At least once daily during continuousfeeds5. Following episodes of vomiting, retchingor coughing (absent coughing does notrule out displacement)6. Following evidence of displacement (e.g.loose tape or tube visibly longer)

While Inserting a NG Tube

If no aspirate is obtained:Try changing the patient’s positionIf still unsuccessful, inject 1ml (neonates),5mls (children) or 30mls (adults) of air downthe NG tube.Wait 15-30 minutes and try to aspirate again.If unsuccessful, advance tube by 1-2cm /10-20cm and try aspirating again.If no gastric juice is aspirated, then ClinicalNutrition Nurse and/or Medical Officer are toconsider a Chest X-Ray.

During Reinsertion of a NGT

If on PPIs, H2 blockers and antacidsthen:Follow the NG tube insertion procedureTake a Chest X-Ray each time a NG tubeis insertedIf position is confirmed start feeding

If:1. On no PPIs, H2 blockers and antacids2. Length of tube is known3. Gastric aspirate has a pH ≤ 4then:Follow the NG tube insertion procedureDocument details and methods ofconfirming placement of NGTNo need for Chest X-RayStart feeding

If…

1. pH of gastric juice for a particular patientis repeatedly higher than 4, &2. Chest X-ray taken on insertion has shownNG tube is in place, &3. The length of the tube out of the nostrilhas remained constant,then tube can be used for feeding and onecan assume a normal pH for the patient.

Patient has a short/medium-term NG tubein situ, andPatient does not dislodge NG tubefrequently, orPatient needs a NG tube for long-termuse, then:Consider insertion of a fine-borepolyurethane NG tube or P.E.G.Consult Clinical Nutrition Nurses

Patient has been on NG tube feeding

for a long time, andPatient starts to show signs ofswallowing, then:Consult Speech Language TherapistsTo assess swallowing reflexConsult Clinical Nutrition NursesTo consider stopping NG feeding

Flowchart For Confirming NG TubePosition