St. Luke’s University Health Network
Nasogastric Tubes
Review Insertion, Care and Maintenance
February 2014
0.5 CE/Credit
Directions for Completion
This program is intended for RNs who are responsible for the care of patients with NG tubes.
Your patient care manager or educator will communicate whether or not this program is required for your unit/department.
1. Before proceeding to the posttest, be sure you have read and understand the following information.
2. Complete the posttest which is final step of this education.
P “Take Test” may be a posttest or acknowledgment statement.
P Remember, no attendance record is needed.
P Completion of the posttest will be sent electronically to your EduTracker record once a 100% is achieved.
P Print the Certificate of Completion for your records if desired or if required for participating in a unit-based competency demonstration.
3. Comments, question, or suggestions can be directed to Tiziana Jones, MSN, RN-BC at 484-526-1800.
Due to some recent inconsistencies in nursing practice, the following information was developed as a review expectations related to the care and maintenance of NG Tubes at St. Luke’s.
Objectives:
After completing the program, the learner will be able to:
· Distinguish between 2 types of NG Tubes and their indications for use.
· Describe process for insertion, assessment, care and maintenance, troubleshooting, and removal of a NG tube.
· Delegate appropriate aspects of NG Tube maintenance to assistive personnel.
Purpose of a Nasogastric Tube
The purpose of a nasogastric tube is to decompress the stomach. With gastric decompression, the stomach contents are removed to relieve the stomach and intestines of pressure caused by the accumulation of stomach content.
Gastric decompression is indicated for bowel obstructions and paralytic ileus or bowel/intestinal surgeries. The tube remains in place until the patients has a return in normal bowel function evidence by active bowel sounds on auscultation and/or passing of flatus.
Nasogastric tubes can also be used to provide enteral feedings to patients.
Nursing Note: From the tip of teeth to gastro-esophageal junction is approximately 40 cm in length.
Why is this important?
The RN would be able to recognize if the NG tube has migrated out/in because of the placement of the marking tape.
Example: If assessing the tube marking strip and the RN notes 35 cm, s/he is aware that placement is not correct and it needs to be advanced.
Ileus?
An ileus can be a mechanical or functional obstruction of the intestines characterized by the absence of peristalsis. If the patient is experiencing a mechanical obstruction (feces, volvulus, tumor, etc.), bowel sounds can alternate between being hyperactive (as the gut tries to push feces around the obstruction) or absent (as the gut rests and prepares for the next peristaltic wave). The patient will also complain of pain when bowel sounds are heard. The patient may also present with abdominal distention.
How to assess for an Ileus
· Gently tap the abdomen with a finger - if fluid is present it will sound dull.
· Palpate the abdomen to assess for pain and rigidity.
· Is patient nauseous?
Post-operative patients are at risk for developing an ileus due to immobility and narcotic use. To prevent obstructions, encourage your patient to get out of bed and ambulate at least three times a day. Minimize fluid intake to prevent production of bile production and nausea.
Go on to the next page…
Common Types of Nasogastric Tubes
Salem Sump Tube is the most common tube used to decompress the stomach, gastric lavage or enteral feeding. It is a double lumen tube with an air vent (blue pigtail) which allows atmospheric air to enter the patient’s stomach so that the tube can float freely, thus preventing the NG tube from adhering to and damaging the gastric mucosa.
Sizes are 14 to 18 with a length of 120 cm. Markings are in “cm” along the tubing.
The larger tube (typically clear) is connected to suction, an advantage to using this type of tube is the ability to maintain continuous suction. Continuous suction is appropriate and safe with a Salem Sump because the air lumen prevents suction from being applied to the stomach wall, causing mucosal damage.
The smaller, blue vent tube should be open to air to provide continuous atmospheric air irrigation. A one-way valve (anti-reflux valve or ARV), when present on the end, prevents reflux of gastric contents out of the vent tubing. To prevent reflux, the tube should always be above the patient’s waist.
· To reestablish a buffer of air between the gastric content and the vent, inject 20 mL of air into the blue vent
· NEVER clamp the air vent, connect it with suction or use if for irrigation.
· Check vent to see if clogged.
· The blue vent side should be in the blue tubing, the white side (with holes) should be facing out to allow air flow.
· Applied correctly to the suction portion of tube and stomach contents are being emptied. The absence of the "whistle" when suction is being applied will alert you to a potential clog at the distal end of the tube.
Levin Tube is a single tube that is used to decompress the stomach, withdraw specimens for diagnostics, treat upper gastrointestinal bleeding, and/or perform lavage.
The tube ranges in size from 14F to 18F with a length of 128 cm. There are no numerical numbers on the tube. There are long circular markings at specific points on the tube to identify and monitor insertion/placement.
The Levin tube is normally set to low intermittent suction to avoid erosion or tearing of the stomach lining causing mucosal damage.
What’s lavage? The irrigation or washing out of a body cavity or part.
Pediatric NG tubes are not normally recommended for adults due consistency of secretions and the relative size of the lumen on a pediatric tube.
Intermittent versus Continuous Suction
Intermittent suction provides alternate periods of gastric-tube suction force followed by a release of suction, which reduces the risk of mucosal tear.
Continuous suction is suction with no interruptions.
Suction should be checked every 4 hours to ensure that gastric content is flowing in the direction of the collection canister.
How do you do this?
Inspect suction apparatus. Check that setting is correct for type of suction (continuous or intermittent), range of suction (low, medium, high) and that movement of drainage through tubing is present.
NG Tube Insertion REVIEW
How to insert an NG Tube:
1. Obtain order (physician, advance practitioner, etc.) for insertion, type of tube, suction
2. Assess patient for high risk contraindications such as:
· craniofacial surgery/trauma
· esophageal varices
· esophageal perforation
· gastrectomy
3. Explain the purpose of the NG tube and the procedure to the patient.
4. Assess patient’s gag reflex (ability to swallow water)
5. Obtain supplies
NG tube / Working suctionSuction tubing / Emesis basin
NG holder / Towel
Safety pin / Gloves
NG drainage canister / NGT Statlock
60 mL syringe / Indelible black marker
Water-soluble lubricant. / Tape
Cup of water
6. Wash hands and apply gloves
7. Inspect the nares for patency
- Assess if patient has deviated septum or any complications with breathing
- If patient has difficulty breathing from one nostril, use the one that is most patent
8. Place patient in high-Fowlers position; have emesis basin ready; remove dentures; cover patient’s chest with a towel
9. Determine length of tube to be inserted
- Using the nasogastric tube, measure from the tip of the patient’s nose > extend tube to the tip of the earlobe > then down to the xiphoid process
- This is the approximate length that needs to be inserted for proper functioning
- With a piece of tape, identify the expected point of exit on the NGT.
10. Lubricate 2-3 inches of the NGT tip with water-soluble lubricant
11. Have the patient take a deep breath and slowly insert tube into nostril and advance to posterior pharynx
· Talk the patient through what you are doing; provide encouragement
· Patient may gag at this point, allow time to rest before continuing
· Have the patient tilt head forward and slowly take a sip of water
· Gently rotate the tube 180 degrees to redirect the curve - this action prevents the tube from entering the mouth
· Slowly advance the tube, as the patient is swallowing until at desired length
If the patient has severe respiratory distress, unable to speak, resistance or
significant nasal hemorrhage, STOP advancing the tube and withdraw it. Assess the
patient.
12. Ask the patient to talk; if the patient cannot talk, the NGT is coiled in throat
13. Temporarily tape the tube to the patient’s nose
14. Assess placement
· Using a 60 mL syringe, attach to end of NG tube and pull back on the plunger. You will be pulling back gastric content. Observe contents for color, particulates, etc. Discard the gastric content.
· Place your stethoscope over the stomach and inject 30 mL of air into the NG tube.
o Ausculate for air in the stomach to confirm placement.
o Evidence based practice is to check the pH of the stomach content and/or obtain xray although these are not current practice at St. Luke’s.
15. Attach the tube to suction as ordered. (Continuous or Intermittent). Ensure suction working.
16. After confirming placement, remove the tape from the nose, apply skin prep, and apply NG StatLock to the NG tube at the bridge of the nose.
17. Anchor the NG tube to the patient’s gown with a piece of tape wrapped around the NG tube and pinned to the patients’ gown.
18. Document
· Type of tube
· Nostril
· Location of tube (cm) or marking
· Volume, color, content or gastric contents aspirated
· Suction level
· Also document the cm measurement or striped marking on SBAR.
High Fowler’s Position?
The upper half of the patient's body is in an upright position (90 degree) and the legs of the patient may be straight or bent.
RN Care and Maintenance of NGT
General Care and Maintenance:
1. Assess and document at least every 8 hours:
· intake and output must be performed to monitor for dehydration.
· volume, color, and consistency and odor of gastric contents
· verify NG tube placement (marking in cm) (tube can migrate out)
· provide frequent nose care; assess NG tube is securely in place; assess for skin breakdown may need to obtain order for Vaseline ointment to lubricate nostril to prevent erosion)
2. Intermittent flushing (irrigation) is recommended every 4 hours to ensure patency or as per MD order.
· Before irrigation, assess the tubes placement by verifying the marking on the tube at the level of the nose
· Prepare a 60 mL syringe with 30 mL of water
· Place chucks or towel under the tube prior to disconnecting to prevent gastric content from getting on linen
· Disconnect the proximal end of the NG tube and the distal end of the suction tubing
· Place syringe in NG tube and slowly instill the water into the NG tube and reconnect the tube to suction
3. Remember, gastric content contains electrolytes and essential fluid. It is important to monitor lab values such as Potassium, Magnesium and Sodium.
4. Frequent mouth care is important to perform to prevent infections. If MD order obtained, administer ice chips to prevent dry mucous membranes and help with comfort.
5. Replace StatLock at least every 48 hours; hold NGT securely and remove StatLock, clean nose, apply skin barrier, then apply new StatLock
6. Encourage coughing and deep breathing to prevent mucous buildup (sinusitis) because of the presence of the NG tube. Encourage incentive spirometry use.
7. If Salem Sump, assess vent each shift for potential clogging; clean if necessary; whistling? If no, instill 20 mL air through blue port
8. Do not manipulate NG tube for patients who have had gastric bypass, Whipple, perforated ulcers, esophagectomy.
Troubleshooting:
· If the NG tube is not draining, the RN should reposition NGT by advancing or withdrawing it slightly with MD order. Always check placement after repositioning.
· Check the Salem Sump tube patency by placing the vent port close to your ear: whistling?
· If NG tube is not draining, flush tubing to canister.
· Check canister for cracks which can affect pressure.
· If the patient vomits with NG tube, notify physician. Assess patient for respiratory distress. NG tube may either need to be repositioned by inserting it several cm or pulled out because it is inserted to far. X-ray may be done to check placement.
Administering Medications:
Administer medications via NG tube if ordered by NG route :
· Flush tube with 30 mL water
· Administer the medication
· Flush with 30 mL water
· Clamp the NG tube for 30 - 45minutes after instilling medication to ensure absorption of medications
· To “clamp” - use a catheter plug in the suction tube. Do not clamp the blue vent. If possible, convert medication to IV form.
NOTE: Medications should be dispensed in liquid form whenever possible.
· DO NOT CRUSH ENTERIC COATED TABLETS
· Crush tablets thoroughly and dissolve in water.
· Always check with Pharmacy prior to crushing a medication. Some medications have the potential to produce an altered pharmacologic effect if crushed.
Removing an NG tube:
1. Removal of NG tube requires an MD order
2. A clamping trial may be ordered prior to removal
o A clamping trial is done to determine if the patient can tolerate not having the tube
o Clamp the tube for 4 hours or per MD order
o Assess the patient for nausea, vomiting or abdominal distension.
o If the patient is uncomfortable, notify the MD for further orders.
In most cases, if the patient has any of the above, the trail failed and it is unlikely the tube will be removed at this time