INSERTING A NASOGASTRIC TUBE

PURPOSES
To administer tube feedings and medications to clients unable to eat by mouth or swallow a
sufficient diet without aspirating food or fluids into the lungs
To establish a means for suctioning stomach contents to prevent gastric distention, nausea,
and vomiting
To remove stomach contents for laboratory analysis
To lavage (wash) the stomach in case of poisoning or overdose of medications
ASSESSMENT
Check for history of nasal surgery or deviated septum. Assess patency of nares.
Determine presence of gag reflex.
Assess mental status or ability to participate in the procedure.
PLANNING

Before inserting a nasogastric tube, determine the size of tube to be inserted and whether
the tube is to be attached to suction.

Equipment
Large- or small-bore tube (nonlatex
preferred)

pH test strip or meter

Nonallergenic adhesive tape, 2.5 cm (1 in.)

Stethoscope

Clean gloves

Disposable pad or towel

Water-soluble lubricant

Clamp or plug (optional)

Facial tissues

Antireflux valve for air vent if Salem sump

Glass of water and drinking straw

Suction apparatus
Safety pin and elastic band
CO2 detector (optional)

IMPLEMENTATION

Preparation

Assist the client to a high Fowlers position if his or her health condition permits, and
support the head on a pillow.

Rationale: It is often easier to swallow in this position and gravity helps the passage of
the tube.

Place a towel or disposable pad across the chest.

Performance

1. Prior to performing the insertion, introduce self and verify the clients identity using
agency protocol. Explain to the client what you are going to do, why it is necessary, and
how he or she can participate. The passage of a gastric tube is unpleasant because the
gag reflex is activated during insertion. Establish a method for the client to indicate
distress and a desire for you to pause the insertion. Raising a finger or hand is often used
for this.

2. Perform hand hygiene and observe other appropriate infection control procedures (e.g.,
clean gloves).

3. Provide for client privacy.

4. Assess the clients nares.

Apply clean gloves.

Ask the client to hyperextend the head, and, using a flashlight, observe the intactness of
the tissues of the nostrils, including any irritations or abrasions.

Examine the nares for any obstructions or deformities by asking the client to breathe
through one nostril while occluding the other.

Select the nostril that has the greater airflow.

5. Prepare the tube.

If a small-bore tube is being used, ensure stylet or guidewire is secured in position.

Rationale: An improperly positioned stylet or guidewire can traumatize

If a large-bore tube (e.g., Salem sump tube) is being used, place the tube in a basin of
warm water while preparing the client.

Rationale: This allows the tubing to become more pliable and flexible. However, if the
softened tube becomes difficult to control, it may be helpful to place the distal end in a
basin of ice water tohelp it hold its shape. the nasopharynx, esophagus, and stomach.

6. Determine how far to insert the tube.

Use the tube to mark off the distance from the tip of the clients nose to the tip of the
earlobe and then from the tip of the earlobe to the tip of the xiphoid.

Rationale: This length approximates the distance from the nares to the stomach. This
distance varies among individuals.

Mark this length with adhesive tape if the tube does not have markings. 7. Insert the
tube.

Lubricate the tip of the tube well with water-soluble lubricant or water to ease insertion.
In some agencies, topical lidocaine anesthetic is used on the tube or in the clients nose to
numb the area

Rationale: A water-soluble lubricant dissolves if the tube accidentally enters the lungs.
An oil-based lubricant, such as petroleum jelly, will not dissolve and could cause
respiratory complications if it enters the lungs.

Insert the tube, with its natural curve toward the client, into the selected nostril. Ask the
client to hyperextend the neck, and gently advance the tube toward the nasopharynx.

Rationale: Hyperextension of the neck reduces the curvature of the nasopharyngeal

Direct the tube along the floor of the nostril and toward the ear on that side.

Rationale: Directing the tube along the floor avoids the projections (turbinates)along the
lateral wall.

Slight pressure and a twisting motion are sometimes required to pass the tube into the
nasopharynx, and some clients eyes may water at this point.

Rationale: Tears are a natural body response. Provide the client with tissues as needed.

If the tube meets resistance, withdraw it, relubricate it, and insert it in the other nostril.

Rationale: The tube should never be forced against resistance because of the danger of
injury.

Once the tube reaches the oropharynx (throat), the client will feel the tube in the throat
and may gag and retch. Ask the client to tilt the head forward, and encourage the client to
drink and swallow.

Rationale: Tilting the head forward facilitates passage of the tube into the posterior
pharynx and esophagus rather than into the larynx; swallowing moves the epiglottis over
the opening to the larynx.

If the client gags, stop passing the tube momentarily. Have the client rest, take a few
breaths, and take sips of water to calm the gag reflex.

In cooperation with the client, pass the tube 5 to 10 cm (2 to 4 in.) with each swallow,
until the indicated length is inserted.

If the client gags, stop passing the tube momentarily. Have the client rest, take a few
breaths, and take sips of water to calm the gag reflex.

In cooperation with the client, pass the tube 5 to 10 cm(2 to 4 in.) with each swallow,
until the indicated length is inserted.

If the client continues to gag and the tube does not advance with each swallow,
withdraw it slightly, and inspect the throat by looking through the mouth.

Rationale: The tube may be coiled in the throat. If so, withdraw it until it is straight, and
try again to insert it.

If a CO2 detector is used, after the tube has been advanced approximately 30 cm (12 in.),
draw air through the detector. Any change in color of the detector indicates placement of
the tube in the respiratory tract (Meyer et al., 2009). Immediately withdraw the tube and
reinsert.

8. Ascertain correct placement of the tube.

Aspirate stomach contents, and check the pH, which should be acidic.

Rationale: Testing pH is a reliable way to determine location of a feeding tube. Gastric

Aspirate can also be tested for bilirubin. Bilirubin levels in the lungs should be almost
zero, while levels in the stomach will be approximately 1.5 mg/dL and in the intestine more
than 10 mg/dL.

Almost all nasogastric tubes are radiopaque, and position can be confirmed by x-ray.
Check agency policy. If a small-bore tube is used, leave the stylet or guidewire in place

until correct position is verified by x-ray. If the stylet has been removed, never reinsert it
while the tube is in place.

Rationale: The stylet is sharp and could pierce the tube and injure the client or cut off
the tube end.

Place a stethoscope over the clients epigastrium and inject 10 to 30 mL of air into the
tube while listening for a whooshing sound. Although still one of the methods used, do not
use this method as the primary method for determining placement of the feeding tube.

Rationale: This method does not guarantee tube position.

If the signs indicate placement in the lungs, remove the tube and begin again.

If the signs do not indicate placement in the lungs or stomach, advance the tube 5 cm (2
in.), and repeat the tests. 9. Secure the tube by taping it to the bridge of the clients nose.

If the client has oily skin, wipe the nose first with alcohol to defat the skin.

Cut 7.5 cm (3 in.) of tape, and split it lengthwise at one end, leaving a 2.5-cm (1-in.) tab
at the end.

Place the tape over the bridge of the clients nose, and bring the split ends either under
and around the tubing, or under the tubing and back up over the nose. Ensure that the
tube is centrally located prior to securing with tape to maximize air flow and prevent
irritation to the side of the nares.

Rationale: Taping in this manner prevents the tube from pressing against and irritating
the edge of the nostril.

10. Once correct position has been determined, attach the tube to a suction source or
feeding apparatus as ordered, or clamp the end of the tubing.

11. Secure the tube to the clients gown.

Loop an elastic band around the end of the tubing, and attach the elastic band to the
gown with a safety pin. or

Attach a piece of adhesive tape to the tube, and pin the tape to the gown. Rationale:
The tube is attached to prevent it from dangling and pulling. If a Salem sump tube is used,
attach the anti reflux valve to the vent port (if used) and position the port above the
clients waist.

Rationale: This prevents gastric contents from flowing into the vent lumen.

Remove and discard gloves. Perform hand hygiene.

12. Document relevant information: the insertion of the tube, the means by which correct
placement was determined, and client responses (e.g., discomfort or abdominal
distention).

13. Establish a plan for providing daily nasogastric tube care.

Inspect the nostril for discharge and irritation.

Clean the nostril and tube with moistened, cotton tipped applicators.

Apply water-soluble lubricant to the nostril if it appears dry or encrusted.

Change the adhesive tape as required.

Give frequent mouth care. Due to the presence of the tube, the client may breathe
through the mouth.

14. If suction is applied, ensure that the patency of both the nasogastric and suction tubes
is maintained.

Give frequent mouth care. Due to the presence of the tube, the client may breathe
through the mouth.

14. If suction is applied, ensure that the patency of both the nasogastric and suction tubes
is maintained.

Irrigations of the tube may be required at regular intervals. In some agencies, irrigations
must be ordered by the primary care provider. Prior to each irrigation, recheck tube
placement.

If a Salem sump tube is used, follow agency policies for irrigating the vent lumen with air
to maintain patency of the suctioning lumen. Often, a sucking sound can be heard from
the vent port if it is patent. Keep accurate records of the clients fluid intake and output,
and record the amount and characteristics of the drainage.

15. Document the type of tube inserted, date and time of tube insertion, type of suction
used, color and amount of gastric contents, and the clients tolerance of the procedure.